[Scholarly Paper] Nursing Theories Applied to Practice Scenarios

The nature of knowledge has confounded philosophers and scholars for centuries; even one of the earliest, Socrates, famously concluded that the only thing he truly knows is that he knows nothing (PhilHelper, 2013). Despite Socrates’ paradox, however, the quest to establish a unique, foundational body of knowledge has continued in each scientific and social discipline, including nursing. Nursing theorists have identified a variety of ways of knowing that contribute to the nursing perspective, which encompasses evidence-based, scientific, practical knowledge, as well as relational, artistic, and humanistic knowledge. While the broad and holistic nature of nursing knowledge is an asset in patient care, its personal and ethical knowledge aspects pose a challenge for theorists trying to establish a universal, distinct foundation from which all nurses can practice. One such contemporary theorist is Patricia Benner, whose Novice to Expert theory purports that expert nurses rely on a personal, experience-based type of knowledge – specifically intuition – with a holistic perspective, developed through active engagement with patients (Petiprin, 2020). Though parts of the theory have been criticized for being vague and immeasurable, its conceptualization of nursing professional development from novice to expert has a wide range of clinical and educational applicability, particularly in the emergency department, as will be discussed in this paper (English, 1993). The highlight of clinical experience as essential for establishing expert level ways of knowing will also be discussed, contextualized as influential to my epistemological nursing stance.

My Epistemological Nursing Stance

In an influential article on nursing knowledge, Thorne admitted that theorists encounter “well known conundrums” when they “try to create an operational definition of the discipline of nursing,” but she remains certain of her conviction that “the disciplinary lens of nursing… represent[s] a distinctive epistemological perspective on the universe… [that] can be known and taught” (Thorne, 2020, p. 1). I agree with Thorne’s view that nursing derives its practice from a common, foundational form of knowing; however, formalizing this knowledge is unrealistic and complicated because of the patient. As the focus of nursing practice and central to nursing ontology, the subject of nursing knowledge is the patient, who is complex, dynamic, and necessarily contextualized to the extent that it is difficult to ever fully know them. This sentiment is echoed in Kim’s book on nursing philosophy where she stated that “nursing is a human practice discipline… [yet, it] is not possible for one to know… human beings all at once in a unified, comprehensive fashion” (Kim, 2015, p. 57). Kim mentioned other theorists that have emphasized, in a similar vein, the need for multiple perspectives that are used in complement with each other to elucidate as holistic an interpretation of the patient as possible.

My epistemological nursing stance is that nurses cannot rely on any one way of knowing. They must coalesce knowledge from a broad range of perspectives and ways of knowing in order to empower and enable patients to meet positive health outcomes within their unique meaning and context. Furthermore, rather than seeking absolute truths or incontrovertible realities of the patient, nurses recognize the ever-changing nature of humanity and appreciate that their ways of knowing, and consequently knowledge, must continually adapt with the patient, and will necessarily differ between patients. Kim supported this view through her complex, but comprehensive, nursing epistemology that covers various cognitive needs and goes “beyond the way scientific knowledge is produced,” particularly in the client domain as the most fundamental area of nursing knowledge and practice (Kim, 2015, p. 58). Carper believed in the diverse forms of nursing knowledge beyond science, including the ethical, aesthetic, personal, and other humanistic ways of knowing as essential to nursing knowledge (Bonsu, 2012; Thorne, 2020). These alternative ways of knowing that draw from sources beyond empirical science are vital aspects of my epistemological nursing stance, along with additional types of knowledge to satisfy each of Kim’s five cognitive needs, such as general, critical hermeneutic, and situated hermeneutic knowledge (Kim, 2015). Nursing practice relies on nurses’ capability to engage meaningfully with patients to effectively elicit this variety of knowledge and gain a holistic understanding of the patient. Over years of refining patient engagement skills and building experience in adapting these skills to numerous patients, the nurse will develop intuition as the ultimate source of knowledge embodied by an expert nurse (Davis & Maisano, 2016).

Benner’s Novice to Expert Theory

In 1982, Benner constructed a theory of nurse development through five stages from novice to advanced beginner, competent, proficient, and ultimately expert level (Davis & Maisano, 2016). At surface level, this theory appears to be focused on the nurse as a professional entity and, thus, may appear ill-fitting in a discussion of ways of knowing the patient. However, upon deeper analysis, the nurse’s progression from novice to expert is indeed centered around their engagement with and depth of knowing the patient, as well as the accumulation of professional experience, which is also inevitably and ontologically dependent on the diversity of the patient. According to the Novice to Expert theory, a nurse begins in a new practicing environment as a novice without experience, relying predominantly on authority and objective ways of knowing, and lacking clinical judgment required for prioritization and flexible care planning (Davis & Maisano, 2016; Petiprin, 2020). After gaining more experience and clinical judgment, the nurse progresses to advanced beginner with continued reliance on rules and guidelines but increasing pattern recognition in patient situations and outcomes (Petiprin, 2020). Eventually, with experience, the nurse becomes competent; gradually, they become more independent in decision-making and rely more on experience-based knowledge than rules and guidelines (Davis & Maisano, 2016). As the nurse’s perspective becomes more holistic and they can apply knowledge from past experiences to modify and adapt care planning to their unique patients, the nurse attains the level of proficiency (Petiprin, 2020). Finally, a nurse may attain expert status once they rely almost exclusively on experiential knowledge in the ultimate form of intuition; at this point, nurses engage with patients in an interdependent, integral way which further contributes to the depth of their knowledge of the patient (Davis & Maisano, 2016; Petiprin, 2020). The evolution of knowledge in relation to interpretation and understanding of the patient situation is evident; enhanced engagement with patients and increased wealth of experience are fundamental to the nurse’s reliance on ways of knowing that allow nurses to assume a meaningful and holistic perspective on patients. Through increased reliance on intuition as a way of knowing, the expert nurse is theoretically able to respond faster and with greater efficiency to complex situations that rule-based knowledge may insufficiently address, particularly in fast-paced, unpredictable clinical environments such as the emergency department.

Applying Benner’s Theory to Emergency Nursing

The National Emergency Nurses Association (NENA) establishes the standards and scope of emergency nursing practice, and defines emergency nursing as addressing unpredictable and urgent patient needs in a chaotic environment, often with limited resources and time (2018). As a practicing emergency department nurse, I have transitioned over the years from methodical and time-consuming rule and guideline-based knowledge application to rapid and efficient critical analysis of patient situations through an interpersonal and experience-based perspective. My role in the department has advanced in parallel with my efficiency and knowledge base, from working primarily in the ambulatory and sub-acute zones as an advanced beginner nurse to the acute zone as I gained competency. After gathering more experience and becoming proficient, I expect to transition into the triage role, and eventually serve as a charge nurse upon reaching expert level emergency nursing. The emergency nurse responds to patient needs across the lifespan, in any sociopolitical context, at varying health stages, and across economic boundaries. This “multifaceted role enables the emergency nurse to affect the processes and outcomes of concerns such as bioethical issues, humanism, bio psychosocial and spiritual needs of patients, and alternative care modalities in the nurse’s role as patient and/or family advocate” (NENA, 2018). It is evident, then, that the emergency nurse cannot successfully rely on empirical or authoritative knowledge alone to care for patients within such a variable and comprehensive scope; aligning with Benner’s theory, emergency nurses must eventually incorporate personal, aesthetic, and intuitive ways of knowing in order to gain competency, proficiency, and expertise. In my experience, the charge nurse is ideally an expert emergency nurse who possesses a comprehensive perspective, after years of experience, to meet not only direct patient needs, but also those of staff and the department as a whole.

Limitations of Benner’s Theory

Benner’s Novice to Expert theory is founded on the idea that expert nurses are able to employ intuition as a key way of knowing, yet cannot explain their employment of it. The defining “catalyst” to expert intuition is not identified, nor is intuition defined or communicable as experts “are unable to communicate the secrets of their understanding to non-experts” (English, 1993, p. 389). Benner characterized intuition as “an art rather than a science… unique, creative, and cannot be taught (or measured)” (English, 1993, p. 390), which is counterintuitive to a theory built on nursing education and professional development. The expert nurse is meant to serve as a role model and mentor to non-expert nurses, yet this is insensible if they are unable to explain the development of their intuition and the process of deduction behind their clinical judgment (English, 1993). This is especially true of expert nurses training non-expert nurses in the fast-paced emergency department, where the non-expert nurse is often overwhelmed and confused as to how the expert nurse is making rapid, seemingly unprompted, assessments and modifications to patient care plans. Further, some nurses may never achieve the level of intuitive awareness required to achieve expert status, yet the Novice to Expert theory implies that this should be achievable, given the passage of time and accumulation of experience. Benner admits, without explanation, that not all nurses can become experts, which is a defeating and illogical aspect of a professional development theory of a career where ongoing education and quality improvement are paramount (English, 1993).

Conclusion

In relatively ideal conditions, Benner’s theory outlines a path for expertise development and growth that coincides with competency levels necessary to work in certain emergency department zones, making it useful for informing education planning and training of nurses. However, the limitations to Benner’s theory exist in its vagueness regarding the concept of intuition, as well as in its logical conclusion that all nurses will attain an equally vague level of expertise without clear guidelines on how to do so. Unfortunately, the healthcare environment has changed dramatically since the conception of Benner’s theory, and modern nursing conditions are far less than ideal. Short staffing and retention issues are leading to nurses occupying roles that do not coincide with their experience or competency, particularly in the emergency department, ultimately affecting patient outcomes. Additionally, expert nurses are leaving the bedside in large numbers, meaning the loss of role models to train newer nurses. As educational and training curricula have been tailored according to Benner’s model, the application of which is incongruent with modern challenges, perhaps it is time to restructure our departmental training and use this opportunity to address some of the Novice to Expert theory shortcomings. The health care landscape has changed considerably over the past few decades; perhaps the definition of an expert nurse must as well.

References

Bonsu, E. (2012, October 3). Carper’s fundamental ways of knowing. Prezi. https://prezi.com/1mzk2nnhgv_-/carpers-fundamental-ways-of-knowing/

Davis, A., & Maisano, P. (2016). Patricia Benner: Novice to Expert - A Concept Whose Time Has Come (Again). The Oklahoma Nurse: 13-15.

English, I. (1993). Intuition as a function of the expert nurse: a critique of Benner's novice to expert model. Journal of Advanced Nursing 18: 387-393. Web: https://0-doi-org.aupac.lib.athabascau.ca/10.1046/j.1365-2648.1993.18030387.x

Kim, H. S. (2015). The essence of nursing practice: Philosophy and perspective. Springer Publishing Company.

Petiprin, A. (2020). Dr. Patricia Benner Novice to Expert - Nursing Theorist. Nursing Theory. https://nursing-theory.org/nursing-theorists/Patricia-Benner.php

PhilHelper. (2013, September 6). Intro to Epistemology #1: The Nature of Knowledge [Video]. YouTube. https://www.youtube.com/watch?v=J1Fn_dpiCCM

National Emergency Nurses Association. (2018). Emergency Nursing: Scope and Standards of Canadian Practice 6th ed. Web: https://nena.ca/w/wp-content/uploads/2018/11/Standards-of-ED-Nursing-Practice-2018.pdf

Thorne, S. (2020). Rethinking Carper's personal knowing for 21st century nursing. Nursing Philosophy, e12307. https://doi.org/10.1111/nup.12307