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CHAPTER 9 Patricia Benner 127

as part of the AMICAE project. Paired interviews & Greenfield, 1993; Lock & Gordon, 1989; Nuccio,
with preceptors and preceptees were “aimed at dis- Lingen, Burke, et al., 1996; Silver, 1986a, 1986b). The
covering if there were distinguishable, characteristic domains and competencies have also been useful for
differences in the novice’s and expert’s descriptions ongoing articulation of the knowledge embedded in
of the same clinical incident” (Benner, 1984a, p. 14). advanced practice nursing (Brykczynski, 1999; Fenton,
Additional interviews and participant observations 1985; Fenton & Brykczynski, 1993; Lindeke, Canedy, &
were conducted with 51 nurse-clinicians and other Kay, 1997; Martin, 1996).
newly graduated nurses and senior nursing students Benner and Wrubel (1989) have further explained
to “describe characteristics of nurse performance and developed the background to the ongoing study
at different stages of skill acquisition” (Benner, of the knowledge embedded in nursing practice in
1984a, p. 15). The purpose “of the inquiry has been The Primacy of Caring: Stress and Coping in Health
to uncover meanings and knowledge embedded in and Illness. They note that the primacy of caring
skilled practice. By bringing these meanings, skills, is three-pronged “as the producer of both stress
and knowledge into public discourse, new knowl- and coping in the lived experience of health and
edge and understandings are constituted” (Benner, illness . . . as the enabling condition of nursing prac-
1984a, p. 218). tice (indeed any practice), and the ways that nursing
Thirty-one competencies emerged from the analy- practice based in such caring can positively affect the
sis of transcripts of interviews about nurses’ detailed outcome of an illness” (1989, p. 7).
descriptions of patient care episodes that included Benner extended the research presented in From
their intentions and interpretations of events. From Novice to Expert (1984a) and features this work in
these competencies, which were identified from ac- Expertise in Nursing Practice: Caring, Clinical Judg-
tual practice situations, the following seven domains ment, and Ethics (Benner, Tanner, & Chesla, 1996;
were derived inductively on the basis of similarity of 2009). This book is based on a 6-year study of
function and intent (Benner, 1984a): 130 hospital nurses, primarily critical care nurses,
1. The helping role examining the acquisition of clinical expertise and
2. The teaching-coaching function the nature of clinical knowledge, clinical inquiry,
3. The diagnostic and patient monitoring function clinical judgment, and expert ethical comportment.
4. Effective management of rapidly changing situations The key aims of the extension of this research were
5. Administering and monitoring therapeutic inter- as follows:
ventions and regimens • Delineate the practical knowledge embedded in
6. Monitoring and ensuring the quality of health care expert practice.
practices • Describe the nature of skill acquisition in critical
7. Organizational work role competencies care nursing practice.
Each domain was developed using the related • Identify institutional impediments and resources for
competencies from actual practice situation descrip- the development of expertise in nursing practice.
tions. Benner presented the domains and competen- • Begin to identify educational strategies that en-
cies of nursing practice as an open-ended interpretive courage the development of expertise.
framework for enhancing the understanding of the In the introduction to the 1996 work, Benner
knowledge embedded in nursing practice. As a result stated, “In the study we found that examining the
of the socially embedded, relational, and dialogical nature of the nurse’s agency, by which we mean the
nature of clinical knowledge, domains and competen- sense and possibilities for acting in particular clinical
cies should be adapted for use in each institution situations, gave new insights about how perception
through the study of clinical practice at each specific and action are both shaped by a practice community”
locale (Benner & Benner, 1999). Such adaptations (Benner, Tanner, & Chesla, 1996, p. xiii). This study
have been implemented in many institutions for nurs- resulted in a clearer understanding of the distinctions
ing staff in hospitals around the world (Alberti, 1991; between engagement with a problem or situation and
Balasco & Black, 1988; Brykczynski, 1998; Dolan, the requisite nursing skills of interpersonal involve-
1984; Gaston, 1989; Gordon, 1986; Hamric, Whitworth, ment. It appears that these nursing skills are learned