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128 UNIT II Nursing Philosophies

over time experientially. The skill of involvement Identification of clinical grasp and clinical fore-
seems central in gaining nursing expertise. Under- thought (two pervasive habits of thought linked
standing of the interlinkage of clinical and ethical with action in nursing practice in phase two of this
decision making (i.e., how an individual’s notions of articulation project) enriched the understanding of
good and poor outcomes and visions of excellence clinical judgment (Benner, Hooper-Kyriakidis, &
shape clinical judgments and actions) was enhanced Stannard, 1999). Benner explained that clinical
by this research. This study represents phase one grasp is as follows:
of the articulation project designed to describe the “ . . . clinical inquiry in action that includes
nature of critical care nursing practice. problem identification and clinical judgment
Phase two took place from 1996 to 1997 and in-
cluded 76 nurses (32 of them advanced practice across time about the particular transitions of
particular patients and families. It has four
nurses) from six different hospitals. This work components: making qualitative distinctions,
is presented in Clinical Wisdom and Interventions engaging in detective work, recognizing chang-
in Acute and Critical Care: A Thinking-in-Action ing clinical relevance, and developing clinical
Approach,which was published in 1999 and updated knowledge in specific patient populations.”
and enlarged in 2011 by Benner, Hooper-Kyriakidis, (Benner, Hooper-Kyriakidis, & Stannard,
and Stannard.The following nine domains of critical 1999, p. 317)
care nursing practice were identified as broad
themes in this work: Benner added that clinical forethought, although it
1. Diagnosing and managing life-sustaining physio- plays a role in clinical grasp, “also plays an essential
logical functions in acute and unstable patients role in structuring the practical logic of clinicians.
2. Using the skilled know-how of managing a crisis Clinical forethought refers to at least four habits of
3. Providing comfort measures for the acute criti- thought and action: future think, clinical forethought
cally ill about specific diagnoses and injuries, anticipation of
4. Caring for patients’ families risks for particular patients, and seeing the unex-
5. Preventing hazards in a technological environ- pected” (Benner, Hooper-Kyriakidis, & Stannard,
ment 1999, p. 317).
6. Facing death: end-of-life care and decision making
7. Communicating and negotiating multiple perspec-
tives Major Assumptions
8. Monitoring quality and managing breakdown Benner incorporates the following assumptions (as
9. Using the skilled know-how of clinical leadership delineated in Brykczynski’s 1985 dissertation; see also
and the coaching and mentoring of others Benner 1984a) in her ongoing articulation research:
These nine domains of critical care nursing practice • There are no interpretation-free data. This aban-
were used as broad themes to interpret the data and dons the assumption from natural science that
incorporate descriptions of the following nine aspects there is an independent reality whose meaning
of clinical judgment and skillful comportment: can be represented by abstract terms or concepts
1. Developing a sense of salience (Taylor, 1982).
2. Situated learning and integration of knowledge • There are no nonreactive data. This abandons the
acquisition and knowledge use false belief from natural science that one can
3. Engaged reasoning-in-transition neutrally observe brute data (Taylor, 1982).
4. Skilled know-how • Meanings are embedded in skills, practices, inten-
5. Response-based practice tions, expectations, and outcomes. They are taken
6. Agency for granted and often are not recognized as knowl-
7. Perceptual acuity and interpersonal engagement edge. According to Polanyi (1958), a context pos-
with patients sesses existential meaning, and this distinguishes it
8. Integrating clinical and ethical reasoning from “denotative or, more generally, representative
9. Developing clinical imagination meaning” (p. 58). He claims that transposing a