Florence Nightingale understood the importance of nursing competence long before it became a favorite topic of conversation in our profession. Her passion for excellence in nursing shines through in the letters she wrote. For example, several letters from 1861 refer to the need to provide training and to attract qualified candidates.1 However, Nightingale also knew that completing a basic nursing education didn’t guarantee competency years later and even recommended that nurses receive certificates for recent experience, a concept analogous to today’s continuing education.2
As our profession evolves, competency in a rapidly changing healthcare environment remains a key component of excellent nursing care. Competency gives us confidence to care for our patients. But developing competency is only one step to becoming an expert nurse. Nurses’ expertise grows over the years — a product of experiences. This module addresses how expertise develops from novice to expert and the importance of supporting one another with this challenging journey.
A well thought-out orientation program is the key to getting off to a good start. Consider the case of Emily Levine. Emily, an excited new grad, reports to duty at her dream job: a staff nurse in the ICU in a large hospital. Full of hope and confident the hospital is the right fit, Emily meets Kelly, her preceptor, who has worked in the ICU for seven years, and the other team members.
Kelly helps Emily identify her learning needs and provides frequent, positive feedback. Kelly assigns Emily to care for patients with similar conditions so she can improve her clinical reasoning ability. Kelly helps Emily identify priorities and points out complications that may occur in her patients. Emily attends a support group of new grad nurses at the hospital to discuss her experiences.
After orientation ends, Emily is surrounded by nurses who mentor and nurture her growth as a professional, competent nurse. She benefits from attending ongoing support group meetings. By the end of a year, Emily is happy in her position and well on her way to becoming a clinically competent nurse.
But not all nurses have an experience like Emily’s. Too often, nurses find a gap between what they learned in schools and what they experience in the clinical setting.3 They find themselves in a “trial by fire” with no one to turn to help them with patient and practice dilemmas. This stress and lack of support causes job dissatisfaction and makes good nurses leave in search of greener pastures.
We can’t afford to lose good nurses simply because they aren’t given the support that every new nurse needs to become a good clinician. From patient care perspectives and from moral and professional perspectives, we owe it to our peers to help them grow and succeed. From a financial perspective, nurturing and retaining nurses is extremely important. It can cost almost $97,000 to teach one new nurse what he or she needs to know to become competent in one year.4 What organization can afford to keep paying this price only to lose the nurses it hired? Nurses have legitimate needs that must be addressed to help them succeed and keep patients safe.
One of the most useful frameworks for addressing nurses’ needs at various stages of professional growth is the model of the stages of clinical competence first described by Patricia Benner, RN, PhD, FAAN
, in her classic book, “From Novice to Expert: Excellence and Power in Clinical Nursing Practice,” published in 1984, with a commemorative edition in 2001.5
Benner, along with coauthors Christine Tanner, RN, PhD, FAAN, and Catherine Chesla, RN, DNSc, FAAN
, expanded on these themes in the second edition of their book “Expertise in Nursing Practice: Caring, Clinical Judgment, and Ethics.”6
The Benner model can help nurses understand how expertise develops, allowing them to support and nurture each other.
Benner’s Stages of Clinical Competence
Stage 1: Novice. Beginners have no experience with the situations in which they are expected to perform. They learn context-free rules to apply universally. For example, “Check the blood pressure every hour. If the diastolic is over 100 mmHg, call the physician.” But rules can’t tell a novice which tasks to perform in each actual situation, so behavior in the clinical setting is limited and inflexible. Novices have a very limited ability to predict what might happen in a particular patient situation. A number of important signs and symptoms, e.g., changing mental status, can only be recognized and assessed after a novice has had experience with patients with similar symptoms.6
Stage 2: Advanced beginner. Nurses have had enough experience to note recurring, meaningful components of a situation. The advanced beginner begins to formulate guidelines that dictate actions. They are new grads in their first job. They have “knowledge, skills and know-how but don’t have many in-depth encounters with a similar patient population,” Benner says.
Stage 3: Competent. These nurses begin to see their actions in terms of long-range goals or plans. Competent nurses lack the speed and flexibility of proficient nurses but have a feeling of mastery and can rely on advanced planning and organizational skills. An increasing sense of saliency helps them recognize what is important. They begin to recognize patterns and the nature of a clinical situation more quickly and accurately. They need to examine fewer options to make decisions.
Stage 4: Proficient. The nurse views situations as “wholes” rather than parts, and maxims, reflecting nuances of a situation, guide performance. The proficient nurse learns from experience what events typically occur and how to modify plans in response to different events. The nurse sees goals and salient facts, but still must consciously make decisions.
Stage 5: Expert. Experts know what needs to be done thanks to a well-developed ability to recognize demands and resources in situations and attain goals. They no longer rely solely on a rule, guideline or maxim to connect understanding of a situation to the appropriate action. They have an intuitive grasp of each situation based on their deep knowledge and experience. They focus on the most relevant problems, not irrelevant alternative options. They use analytical tools only when they have no experience with an event or when events and behaviors don’t occur as expected. The expert often “just knows” a particular situation without internal analysis.
For an idea of the range, consider this example from Benner: Beginning nurses focus on tasks, such as checking vital signs; they basically have a “to do” list. Experts focus on the whole picture even when completing tasks. For example, they note subtle changes, such as a patient’s being a bit harder to arouse than in previous encounters.
Novice to Expert
The Dreyfus Model of Skill Acquisition forms the foundation for Benner’s work. Hubert and Stuart Dreyfus developed their model based on their study of chess players, Air Force pilots and Army commanders and tank drivers.7(Level B)
They contend that expertise is based on experiential learning (learning through reflection on experiences) and situated learning (learning that’s situation-based). Learning in context of actual situations is essential for progressing from a novice to an expert in any field.6,7
Benner found parallels in nursing, where improved practice depends on both science and experience. She writes, “At the heart of good clinical judgment and clinical wisdom lies experiential learning from particular cases.”6
Developing those skills is a long, progressive process. Experiential learning requires an engaged learner who is open to growth and development over time.6
Benner and her colleagues say that at the same time nurses are engaged in various situations, learning from them, they develop “skills of involvement” with patients and families. Benner and her colleague define skills of involvement as “knowing how close or distant to be with patients and families in critical times of threat and recovery.”6 These skills are essential for nurses to manage the stress that comes with their careers. Faced with an emotionally challenging patient, an overprotective parent, or a relative who disagrees with a loved one’s end-of-life decision making, nurses must know how to handle the situation to meet the person’s needs while not losing themselves in the process.
Completing the rite of passage from novice to expert isn’t a forgone conclusion. In a telephone interview with Benner, she explained that nurses can gain knowledge and skills (“knowing how”) without ever learning the theory (“knowing that”), which brings expertise.8 Benner’s model has been described as “a seminal qualitative research, which lays the foundation for understanding nursing expertise and skill acquisition.”9
As nurses develop expertise, particular changes in performance occur. They improve their ability to communicate, organize, deal effectively with interruptions, anticipate patient needs and integrate varied nursing roles into their work.10 (Level B)
According to Benner, as expertise grows, nurses move from reliance on abstract principles (principles that may not be practical in the current situation) to the use of concrete examples from the past (they remember a similar patient that had similar complex issues). They move from viewing a situation in bits to viewing it as a whole. They are involved performers, rather than detached observers.9
These cumulative experiences help nurses move through the five stages.
The following is a closer look at strategies that help nurses progress through the various stages. As you consider the strategies, remember that nurses who change practice areas may revert to earlier stages of expertise. For example, an expert nurse in the CCU would not be able to immediately function as an expert in the OR although certainly the nurse’s expertise is valuable. Understanding this helps nurses deal with the anxiety and uncertainty associated with changing specialties.