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122 UNIT II Nursing Philosophies

experiential learning and situated thinking and reflec- relation to the works of Heidegger (1962) and Kierkeg-
tion on practice in particular practice situations. She aard (1962). Richard Lazarus (Lazarus & Folkman,
refers to this work as articulation research, defined 1984; Lazarus, 1985) mentored her in the field of stress
as: “describing, illustrating, and giving language to and coping. Judith Wrubel has been a participant and
taken-for-granted areas of practical wisdom, skilled co-author with Benner for years, collaborating on
know-how, and notions of good practice” (Benner, the ontology of caring and caring practices (Benner &
Hooper-Kyriakidis, & Stannard, 1999, p. 5). One of Wrubel, 1989). Additional philosophical and ethical
Benner’s first philosophical distinctions was to differen- influences on Benner’s work include Joseph Dunne
tiate between practical and theoretical knowledge. She (1993), Knud Løgstrup (1995a, 1995b, 1997), Alistair
stated that knowledge development in a practice disci- MacIntyre (1981, 1999), Kari Martinsen (Alvsvåg,
pline “consists of extending practical knowledge (know- 2010), Maurice Merleau-Ponty (1962), Onora O’Neill
how) through theory-based scientific investigations and (1996), and Charles Taylor (1971, 1982, 1989, 1991,
through the charting of the existent ‘know-how’ devel- 1993, 1994).
oped through clinical experience in the practice of that Benner (1984a) adapted the Dreyfus model to clini-
discipline” (1984a, p. 3). Benner believes that nurses cal nursing practice. The Dreyfus brothers developed the
have been delinquent in documenting their clinical skill acquisition model by studying the performance of
learning, and “this lack of charting of our practices and chess masters and pilots in emergency situations (Dreyfus
clinical observations deprives nursing theory of the & Dreyfus, 1980; Dreyfus & Dreyfus, 1986). Benner’s
uniqueness and richness of the knowledge embedded in model is situational and describes five levels of skill
expert clinical practice” (Benner, 1983, p. 36). She has acquisition and development: (1) novice, (2) advanced
contributed to the description of the know-how of nurs- beginner, (3) competent, (4) proficient, and (5) expert.
ing practice. The model posits that changes in four aspects of perfor-
Citing Kuhn (1970) and Polanyi (1958), philoso- mance occur in movement through the levels of skill
phers of science, Benner (1984a) emphasizes the acquisition: (1) movement from a reliance on abstract
difference between “knowing how,” a practical knowl- principles and rules to the use of past, concrete experi-
edge that may elude precise abstract formulations, ence, (2) shift from reliance on analytical, rule-based
and “knowing that,” which lends itself to theoretical thinking to intuition, (3) change in the learner’s percep-
explanations. Knowing that is the way an individual tion of the situation from viewing it as a compilation of
comes to know by establishing causal relationships equally relevant bits to viewing it as an increasingly com-
between events. Clinical situations are always more plex whole, in which certain parts stand out as more or
varied and complicated than theoretical accounts; less relevant, and (4) passage from a detached observer,
therefore, clinical practice is an area of inquiry and standing outside the situation, to one of a position of
a source of knowledge development. By studying involvement, fully engaged in the situation (Benner,
practice, nurses can uncover new knowledge. Nurses Tanner, & Chesla, 1992).
must develop the knowledge base of practice (know- Because the model is situation-based and is not
how), and, through investigation and observation, trait-based, the level of performance is not an indi-
begin to record and develop the know-how of clinical vidual characteristic of an individual performer, but
expertise. Ideally, practice and theory dialog creates instead is a function of a given nurse’s familiarity with
new possibilities. Theory is derived from practice, and a particular situation in combination with her or his
practice is extended by theory. educational background. The performance level can
Hubert Dreyfus introduced Benner to phenomenol- be determined only by consensual validation of ex-
ogy. Stuart Dreyfus, in operations research, and Hubert pert judges and by assessment of the outcomes of the
Dreyfus, in philosophy, both professors at the Univer- situation (Benner, 1984a). In applying the model to
sity of California at Berkeley, developed the Dreyfus nursing, Benner noted that “experience-based skill
Model of Skill Acquisition (Dreyfus & Dreyfus, 1980; acquisition is safer and quicker when it rests upon a
Dreyfus & Dreyfus, 1986), which Benner applied in her sound educational base” (1984a, p. xix). Benner
work, From Novice to Expert (1984a). She credits Jane (1984a) defines skill and skilled practice to mean im-
Rubin’s (1984) scholarship, teaching, and colleagueship plementing skilled nursing interventions and clinical
as sources of inspiration and influence, especially in judgment skills in actual clinical situations. In no case