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CHAPTER 9 Patricia Benner 123

does this refer to context-free psychomotor skills or than intellectual, reflective activity” but argue that in-
other demonstrable enabling skills outside the con- tellectual, reflective capacities are dependent on em-
text of nursing practice. bodied knowing (p. 43). Embodied knowing and the
In subsequent research undertaken to further ex- meaning of being are premises for the capacity to care;
plicate the Dreyfus model, Benner identified two things matter and “cause us to be involved in and
interrelated aspects of practice that also distinguish defined by our concerns” (p. 42).
the levels of practice from advanced beginner to While doing her doctoral studies at Berkeley, Ben-
expert (Benner, Tanner, & Chesla, 1992; 1996). First, ner was a research assistant to Richard S. Lazarus
clinicians at different levels of practice live in different (Lazarus, 1985; Lazarus & Folkman, 1984), who is
clinical worlds, recognizing and responding to differ- known for his stress and coping theory. As part of
ent situated needs for action. Second, clinicians Lazarus’ larger study, Benner studied midcareer
develop what Benner terms agency, or the sense of males’ meaning of work and coping that was pub-
responsibility toward the patient, and evolve into fully lished as Stress and Satisfaction on the Job: Work
participating members of the health care team. The Meanings and Coping of Mid-Career Men (1984b).
skills acquired through nursing experience and the Lazarus’ Theory of Stress and Coping is described as
perceptual awareness that expert nurses develop as phenomenological, that is, the person is understood
decision makers from the “gestalt of the situation” to constitute and be constituted by meanings. Stress is
lead them to follow their hunches as they search for the disruption of meanings, and coping is what the
evidence to confirm the subtle changes they observe person does about the disruption. Both doing some-
in patients (1984a, p. xviii). thing and refraining from doing something are ways
The concept that experience is defined as the out- of coping. Coping is bound by the meanings inherent
come when preconceived notions are challenged, re- in what the person interprets as stressful. Different
fined, or refuted in actual situations is based on the possibilities arise from the way the person is in the
works of Heidegger (1962) and Gadamer (1970). As situation. Benner used this concept to describe clini-
the nurse gains experience, clinical knowledge be- cal nursing practice in terms of nurses making a
comes a blend of practical and theoretical knowledge. difference by being in a situation in a caring way.
Expertise develops as the clinician tests and modifies Benner’s approach to knowledge development that
principle-based expectations in the actual situation. began with From Novice to Expert (1984a) began a
Heidegger’s influence is evident in this and in Benner’s growing, living tradition for learning from clinical
subsequent writings on the primacy of caring. Benner nursing practice through collection and interpreta-
refutes the dualistic Cartesian descriptions of mind- tion of exemplars (Benner, 1994; Benner & Benner,
body person and espouses Heidegger’s phenomeno- 1999; Benner, Tanner & Chesla, 1996; Benner,
logical description of person as a self-interpreting Hooper-Kyriakidis, & Stannard, 1999). Benner and
being who is defined by concerns, practices, and life Benner (1999) stated the following:
experiences. Persons are always situated, that is, they
are engaged meaningfully in the context of where they Effective delivery of patient/family care requires
are. Heidegger (1962) termed practical knowledge as collective attentiveness and mutual support of
the kind of knowing that occurs when an individual is good practice embedded in a moral community of
involved in the situation. By virtue of being humans, practitioners seeking to create and sustain good
we have embodied intelligence, meaning that we come practice... This vision of practice is taken from the
to know things by being in situations. When a familiar Aristotelian tradition in ethics (Aristotle, 1985)
situation is encountered, there is embodied recogni- and the more recent articulation of this tradition
tion of its meaning. For example, having previously by Alasdair MacIntyre (1981), where practice is
witnessed someone developing a pulmonary embolus, defined as a collective endeavor that has notions of
a nurse notices qualitative nuances and has recogni- good internal to the practice... However, such col-
tion ability for observing it before those nurses who lective endeavors must be comprised of individual
have never seen it. Benner and Wrubel (1989) state, practitioners who have skilled know how, craft,
“Skilled activity, which is made possible by our em- science, and moral imagination, who continue to
bodied intelligence, has been long regarded as ‘lower’ create and instantiate good practice (pp. 23-24).