From Novice to Expert

One of most-referenced and well-known nursing theories is Patricia Benner's "From Novice to Expert."  In this simple but remarkably profound model, Benner introduced the concept that expert nurses develop skills and understanding of patient care over time through both a sound educational base as well as a multitude of experiences.  She proposed that one could gain knowledge and skills ("knowing how") without ever learning the theory ("knowing what"). 

Benner suggests five levels of nursing experience: 

1)  The Novice is a true beginner that is primarily governed by rules surrounding a very task-oriented and inflexible role in nursing

2)  The Advanced Beginner, despite acceptable performance, is a nurse that has only begun to channel experience to identify recurring meaningful components in their role

3)  The Competent Nurse is one that is able to draw on experience to apply abstract and critical thinking in order to reach a greater efficacy and organizational level

4)  The Proficient Nurse understands the "big picture" and is not only quick with decision-making but has gained the ability to predict what is next

5) The Expert is a nurse that has gained so much experience that her fluid and flexible actions are based almost entirely on intuition. 

This coveted expertise that Benner speaks of is real and is the trait every young nurse strives to attain.  The Expert is the nurse that can walk into a patient's room, look into his eyes, and know he is in trouble.  The transition from novice to expert moves away from rules and basic knowledge toward sole intuition. 

As you can imagine, this intuition can be extremely dangerous to the egos of fresh interns and some socially-obtunded residents every July.  However, this inevitably protracts the perpetual war:  experienced nurse vs. new physician.  Interns come into the hospital setting thinking they know more than nurses - and, despite what more seasoned nurses will tell you, they do.  They just don't have the experience, fluidity of reaction, and intuition of The Expert Nurse, making them untimately more dangerous to the patient.  In fact, interns are an abundance of knowledge with minimal experience while the Expert Nurse is an abundance of clinical experitise with only basic knowledge.  Now, this is undoubtably a statement that is not true of all nurses.  Proactive nurses that obtain certifications, strive to understand concepts at intricate levels, ask questions, participate in nurse-led rounds when available, and act as a sponge during clinical discussion do not fit into my earlier umbrella statement.  However, what about the nurses that just "get by" and maintain their patients?  We all work under the same license.  We all are expected to complete the mundane tasks of passing meds, washing hair, and inserting foley catheters.  We all start off with the same rudimentary knowledge base and we all inevitably gain the experience that Benner so heavily theorized about.

But, I'd like the challenge Benner's theory.  Not the theory itself, but its acceptance.

As I always point out, physicians learn to suggest treatments because they have the knowledge to diagnose on the differential.  Nurses, on the other hand, are able to suggest treatments because they recognize patterns, making experience a much more valued clinical tool than knowledge.  Why is it experience that makes a nurse valuable instead of knowledge?  Think of the potential of a nurse that had a greater knowledge base and the expertise of The Expert!  My alma mater considered itself progressive for teaching the concept of "critical thinking" as opposed to the more task-oriented education of its diploma counterparts.  Unfortunately, this tradition allows for the perpetual "dumbing down" of all nurses - from novice to expert.