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PATRICIA BENNER (Patricia SAWYER Benner) RN, PhD, FRCN “Caring, Clinical Wisdom, Ethics in Nursing Practice” From Novice to Expert: Excellence and Power in Nursing CREDENTIALS AND BACKGROUND OF THE PHILOSPHER: DOB: August 31, 1942 Hampton, Virginia, USA (82 y/0) Spent her childho...

PATRICIA BENNER (Patricia SAWYER Benner) RN, PhD, FRCN “Caring, Clinical Wisdom, Ethics in Nursing Practice” From Novice to Expert: Excellence and Power in Nursing CREDENTIALS AND BACKGROUND OF THE PHILOSPHER: DOB: August 31, 1942 Hampton, Virginia, USA (82 y/0) Spent her childhood in California 1964 – Bachelor of Arts Degree in Nursing (Pasadena College) 1970 – Master of Science in Surgical Nursing (University of California, SF) 1982 – Ph.D University of Calfiornia, Berkley 1984 – “From Novice to Expert: Excellence and Power in Clinical Nursing Practice’ Benner has a range of clinical experience in medical-surgical, critical care, and home health care A Professor of Doctoral and Master’s and Levels in UCSF Author of 9 books Currently Chief Development Officer for Educating nurses. Com NovEx used in hospital orientation and professional development programs HONORS AND AWARDS: Honorary Member of Royal Danish Nursing Society(2012) Sigma Theta Tau International Book Author Award (2010) 1984, 1989, 1006, 1999, 2011 – American Journal of Nursing Book of the Year awardee for: - The Primacy of Caring, Stress and Coping in Health and Illness (1989) - Expertise in Nursing Practice: Caring, Clinical Judgement, and Ethics (1996) - Novice to Expert: Excellence and Power in Clinical Nursing Practice (1984) CARING, CLINICAL WISDOM, ETHICS IN NURSING PRACTICE Caring practices are imbued with knowledge and skill about everyday human needs, and that to be experienced as caring, these practices must be attuned to the particular person who is being cared for and to the particular situation as it unfolds. PHILOSOPHICAL SOURCES - her thinking in nursing was influenced greatly by Virginia Henderson. - Adapted the Dreyfus model to clinical nursing practice  BENNER'S MODEL 5 Levels of skill acquisition and development: (NACPE) 1. Novice 2. Advanced beginner 3. Competent 4. Proficient 5. Expert 5 LEVELS OF SKILL ACQUISITION AND DEVELOPMENT 1. 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. - What is relevant and irrelevant aspect? - students of nursing - nurse who move and first time in the area 2. ADVANCE BEGINNER - 1 YEAR - Develops when the person can demonstrate marginally acceptable performance - Clinical situations are viewed by nurses as demand of situation rather than needs of patient and responses - guided by rules - focus on task completion 3. COMPETENT - 2-3 YEARS - Most pivotal in clinical learning, because the learner begins to recognize patterns and determine which elements of the situation warrant attention and which can be ignored. - Conscious and deliberate planning that determines which aspects of current and future situations are important and which can be ignored (Benner, 1984a) - focus on time management - works in efficient and organized manner 4. PROFICIENT - 3-4 YEARS - The performer perceives the situation as a whole (the total picture) rather than in terms of aspects, and the performance is guided by maxim (PRINCIPLE) - Demonstrate new ability to see changing relevance in situation - has learned what to expect in certain situations  5. EXPERT - 5-10 YEARS - Is achieved when the performer no longer relies on analytical principle (Rule, guideline, maxim) to connect an understanding of the situation to an appropriate action (Benner, 1984а) KEY ASPECTS OF EXPERT - Demonstrates clinical grasp and resource-based practice - Possessing embodied know-how - Seeing big picture - Seeing the unexpected - having intuitive grasp of the situation - recognize patterns from deep experiential background - highly skilled analytic ability BENNER’S MAJOR CONCEPTS AND DEFINITIONS ASPECTS OF A SITUATION - ASPECT are the recurring meaningful situational components recognized and understood in context because the nurse has previous experience Benner, 1984a). ATTRIBUTES OF A SITUATION - 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 meaning DOMAIN - Is an area of practice having a number of competencies with similar intents, functions, and meanings (Benner, 1984a). - ICU CASES EXEMPLAR - first-person-experience-near narrative of a clinical situation that conveys common taken for granted meanings of nursing practice recognizable by other nurses 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 МАХІМ - Is a cryptic description of skilled performance that requires a certain level of experience to recognize the implications of the instructions (Benner, 1984a). PARADIGM CASE - Is a clinical experience that stands out and alters the way the nurse will perceive and understand future clinical situations(Benner, 1984a) SALIENCE - Describes a perceptual stance or embodied knowledge whereby aspects of a situation stand out as more or less important(Benner, 1984a) ETHICAL COMPORTMENT - Is good conduct born out of an engagement in a particular situation and entails a sense of membership in the relevant professional group. HERMENEUTICS - Means "interpretive". - The term derives from biblical and judicial exegesis. FORMATION - Address the development of sense, esthetics, perceptual acuities, relational skills, knowledge and dispositions that take place as student nurses form professional identity. SITUATED COACHING - Was identified as the signature pedagogy in nursing from the educating Nurses study. (Benner et.al, 2010) THEORETICAL ASSERTIONS The skilled practice of nursing exceeds the bounds of formal theory. Concrete experience facilitates learning about the exceptions and shades of meaning in a situation. BENNER’S THEORY- NURSING PARADIGMS PERSON - 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 life. Four major aspects of Understanding the person: (SEPT) The role of the situation The role of the embodied intelligent agent The role of personal concerns The role of temporarily embodiment SITUATION - Benner and Wrubel (1989) used situation because it conveys a social env’t means being situated and situated meaning which defined by person - Each person’s past, present, and future which include her/his own personal meanings, habits, perspectives, influence the current SITUATION. HEALTH - What can be assessed - not just the absence of disease and illness Disease – what can be assessed at physical level Well-being- human experience of health and wholeness Illness- is the human experience of loss or dysfunction NURSING - Is described as a caring relationship an "enabling condition of connection and concern" - Nursing practice is a care and a study of lived experienced of health, illness, and disease – the relationship of 3 elements - Caring is primary because caring sets up giving and receiving help ACCEPTANCE BY THE NURSING COMMUNITY (PER CSG) 1. PRACTICE - Describes its usefulness for preceptor development, orientation programs, and career development ; Huntsman et al.(1984). Balasco and Black (1988) and Silver (1986a, 1986b) used Benner’s work as a basis for differentiating clinical knowledge development and career progression in nursing. Crissman and Jelsma(1990) applied Benner’s findings to develop a cross-training program to address staffing imbalances. 2. EDUCATION - Benner (1982) critiqued the concept of competency based testing by contrasting it. 3. RESEARCH - Maintains that there is excellence and power in clinical nursing practice made visible through articulation research. 4. CLARITY - An identification with the idea of clinical wisdom and varying levels of clinical expertise development progressed very quickly. 5. SIMPLICITY - The model is relatively simple with regard to the five stages of skill acquisition, and it provides a comparative guide for identifying levels of nursing practice from individual nurse descriptions validated by consensus. 6. GENERALITY - Has universal characteristics; that is, it is not restricted by age, illness, health, or location of nursing practice. JEAN WATSON The Philosophy and Theory of Transpersonal Caring DOB: Oct 06, 1940 - She earned a B.Sc. In 1964, MS in Psychiatric Nusing in 1966 and PhD in Educational Psychology and Counseling in 1973. - Founder of the Center for Human Caring in Colorado The Philosophy and Science of Caring - Defined caring as a nurturing way or responding to a valued client towards whom the nurse feels a personal sense of commitment and responsibility. It is only demonstrated interpersonally that results in the satisfaction of certain human needs. Caring accepts the person as what he/she may become in a caring environment. Ten Caritas Processes 1. Cultivating the Practice of Loving-Kindness and Equanimity Toward Self and Other as Foundational to Caritas Consciousness. 2. Being Authentically Present: Enabling, Sustaining, and Honoring the Faith, Hope, and Deep Belief System and the Inner-subjective World of Self/ Other (Watson, 2008) 3. The cultivation of one's own Spiritual Practices and Transpersonal Self, Going Beyond Ego- Self. 4. Developing a helping- trusting relationship. 5. Being Present to, and Supportive of, the Expression of Positive and Negative Feelings. 6. Creative Use of Self and All Ways of Knowing as Part of the Caring Process; Engage in the Artistry of Caritas Nursing 7. Engage in Genuine Teaching-Learning Experience that Attends to Unity of Being and Subjective Meaning—Attempting to Stay Within the Other's Frame of Reference. 8. Creating a healing environment at all levels 9. Administering Sacred Nursing Acts of Caring- Healing by providing the Basic Human Needs. 10. Opening and Attending to Spiritual/ Mysterious and Existential Unknowns of Life- Death  THEORETICAL ASSERTIONS NURSING - The word NURSE is both a noun, and a verb. - Nurses are interested in understanding health, illness, and the human experience; promoting and restoring health; and preventing illness.. - In her writings, Watson defines nursing as a human science of people and human health-illness experiences that are mediated by professional, personal, scientific, aesthetic, and ethical human care transactions. PERSONHOOD (HUMAN BEING) - Person as unity of mind/ body/ spirit/ nature. - Human being is a valued person to be cared for, respected, nurtured, understood, and assisted. She viewed human as greater than, and different from, the sum of his parts. HEALTH - Unity and harmony within the mind, body and soul, associated with the degree of congruence between the self as perceived and the self as experienced (Watson, 1988) Watson includes these 3 elements: - A high level of over-all physical, mental, and social functioning - A general adaptive-maintenance level of daily functioning - the absence of illness ENVIRONMENT - Attending to supportive, protective, and/ or corrective mental, physical, societal, and spiritual environments ( Watson, 1979) - Environment provides the values that determine how one should behave and what goals one should strive toward. A caring attitude is not transmitted from generation to generation by genes. It is transmitted by the culture of the profession as a unique way of coping with its environment. METAPARADIGM Person A valued being to be cared for, respected, nurtured, understood, and assisted, a fully functional, integrated self Environment Social environment, caring and the culture of caring affects health Health Physical, mental, and social wellness. Refers to unity and harmony within the mind, body, and soul. Nursing A human science of people and human health- illness experiences that are mediated by professional, personal, scientific, aesthetic, and ethical human care transactions.  APPLICATION BY THE NURSING COMMUNITY PRACTICE - validated in outpatient, inpatient and community health clinical settings and with various populations, including recent applications with attention to patient care essentials ( Pipe et al, 2012). - Living on ventilator (Lindahl, 2011) - Simulating care (Diener & Hobbs, 2012). - Mothers struggling with mental illness (Blegen, Erikson, & Bondas, 2014) ADMINISTRATION AND LEADERSHIP - Calls for administrative practices and business models to embrace caring (Watson, 2006a) - Healthcare environment of increased acuity levels of hospitalized individuals, short hospital stays, increasing complexity of technology, and rising expectations in the " task" of nursing. EDUCATION - Gives focus in educating graduate nursing students and providing them with ontological, ethical, and epistemological bases for their practice, along with research directions (Hills & Watson, 2011). RESEARCH - Qualitative, naturalistic, and phenomenological methods have been identified as particularly relevant to the study of caring and to development of nursing as a human science (Nelson & Watson, 2011; Watson, 2012) - Influential in the development of an intervention aimed at increasing nurse retention and reducing compassion fatigue and moral distress in a surgical trauma ICU. FLORENCE NIGHTINGALE (1820-1910) ENVIRONMENTAL THEORY CREDENTIALS AND BACKGROUND OF THE THEORIST: - Founder of modern Nursing Birthdate: May 12, 1820 Birthplace: Florence, Italy - She entered as a 134th nursing student at Fleidner School of Nursing, Kaiserwerth, Germany, a Protestant religious community with a hospital facility - She was there for approximately 3 months and her teachers declared her trained as a nurse. - Florence had a firm faith in God ( she was a Unitarian Christian), and for a time believed she had a religious calling. - Nightingale wrote about her "calling" in her diary (at age 17). “God spoke to me and called me to his service" - Parthenope- older sister of FN Return to England After her return to England, Nightingale was employed to examine hospital facilities, reformatories, charitable institutions. Only 2 yrs after completing her nursing training in 1853 she became the superintendent of the Hospital for Invalid Gentlewomen in London. She was at Kaiserwerth, Germany for approximately 3 months; at the end of that time, her teacher declared her trained as a NURSE. THE LADY WITH A LAMP (CRIMEAN WAR) Sir Sidney Herbert (a family friend and the Secretary of War) requested Florence with the 34 newly recruited nurses to care for the wounded British soldiers. - Scutari, Turkey - She arrived there in November 1854 (age 34) - She was called THE LADY OF THE LAMP, because she made ward rounds during the night. - In Scutari, FN became critically ill with Crimean fever, which may have been typhus or brucelliosis. - Until 80 years of age, she wrote between 15,000 to 20,000 letters to friends, acquaintances, allies, and opponents. - She was able to work in her 80s until she lost vision - She died in her sleep on August 13, 1910 (90 years of age) ENVIRONMENTAL PROBLEMS - She addressed her mission of providing nursing care through the ENVIRONMENTAL PROBLEM existed: 1. lack of sanitation 2. Presence of filth few chamber pots, contaminated water, contaminated bed linens, and overflowing cesspools.) 3. Frostbite 4. Louse infestations 5. Wound infections 6. Opportunistic diseases NURSE STATISTICIAN - She was viewed as pioneer in the graphic display of statistics - Selected a fellow of the Royal Statistical Society in 1858. 1. Notes on Matters Affecting the Health 2. Efficiency and Hospital Administration of British Army. Notes on Hospitals 4. Report on Measures Adopted for Sanitary Improvements in India. AWARDS and LATER LIFE 1. First woman to be granted the Order of Merit (OM) and the Royal Red Cross (RRC) 2. Second most famous British person - Her birthday marks the International Nurses Day celebration each year. (MAY 12, 1820) SOURCES OF KNOWLEDGE (ELIR) 1. EDUCATION 2. LITERATURE- access to persons of power and influence Ex. Charles Dicken's novel The Adventures of Martin Chuzzlewit 3. INTELLECTUALS- political leaders, intellectuals, and social reformers like John Stuart Mill, Benjamin Jowett, Edwin Chadwick and Harriet Marineu 4. RELIGIOUS BELIEFS - Her Unitarian faith strongly supports the education of a person as a means of developing their divine potential and serving them toward perfection strength throughout her life. FN’S 5 ESSENTIAL COMPONENTS OF ENVIRONMENTAL HEALTH: (PLCEP) PURE AIR LIGHT CLEANLINESS EFFICIENT DRAINAGE PURE WATER ACCEPTANCE BY THE NURSING COMMUNITY 1. PRACTICE ENVIRONMENTAL ASPECTS OF NIGHTINGALE'S THEORY: a. Ventilation b. Warmth c. Quiet d. Cleanliness 2. EDUCATION - Firmly considered that better practice could result only from better education. - Measurement of the art of nursing could NOT be accomplished through licensing examinations like testing methods, and case THEORETICAL ASSERTION A. DISEASE - Believed that a disease was a reparative process - Nursing role was to prevent an interruption of the reparative process and to provide optimal conditions for its enhancement. B. NURSE - Women were to be specifically trained to provide care for the sick person. - Concise and clear decision making regarding the patient - Persons desired good health and that they would cooperate with the nurse and nature to allow the reparative process to occur or alter their environment to prevent disease. C. INFECTION - Understood the concept of contagion and contamination through organic materials from the patient and/ or the environment. - Nightingale embrace the concept of vaccination against various disease. - Appropriate manipulations of the environment would prevent disease- modern sanitation activities. MAJOR CONCEPTS: Term SURROUNDING usually referred to as environment. Components: ventilation, warmth, light, diet, cleanliness, and noise.