Teaching and learning implications of the Dreyfus and Dreyfus Skill Acquisition Model
Patricia Benner, R.N., Ph.D., FAAN
May 30, 2022
In this video Patricia Benner describes and explains the changes that occur with the development of expertise and mastery, based upon extensive research using the Dreyfus and Dreyfus model of Skill Acquisition (Benner, Tanner, Chesla, 1996; 2009; Dreyfus, S.E.2014; Dreyfus & Dreyfus, 1988; Dreyfus, H.L., 1986; Dreyfus, H.L., 2017). This research-based understanding of the changes in perceptual grasp, skilled know-how and embodied situated thinking-in-action comes just in time for senior nursing students and new graduates transitioning into their new work roles.
In our highly technical, culture, where the many falsely believe that “theory and technique are the primary sources and generators of all knowledge,” it is essential to recover the understanding that embodied, intelligent, engagement in learning a practice, is not only or always mediated by theories and formal concepts, ideas and templates. Instead practice itself is a way of knowing, in its own right, and learning a practice inevitably uncovers/discovers new knowledge not yet formulated in theories or formal concepts. Theory and practice are intertwined, each as sources of knowledge.
We begin by describing and defining the nature of an organized practice such as nursing, medicine, teaching. Alasdair MacIntyre (2007) defines practice as a “A Self-Improving, Socially Embedded form of Knowledge and Situated Skilled Know-how with notions of good Internal to the Practice (MacIntyre, 2007).” Similarly, in his book Back to the Rough Ground, Joseph Dunne (1997) defines practice as dependent upon engaged, embodied practitioners committed to improving the practice by their responsible engagement in it: “A practice is not just a surface on which one can display instant virtuosity. It grounds one in a tradition that has been formed through an elaborate development and that exists at any juncture only in the dispositions (slowly and perhaps painfully acquired) of its recognized practitioners. (Dunne, 1997, pp. 378-380).” Nurses sometimes diminish this notion of an socially organized, self-improving practice with phrases that point to the practice of nursing as the “mere doing” or carrying out of theories and thinking. It is as if many nurses consider the practice of nursing as a passive, inert, collection of skills, techniques and strategies on which the knowledge of external theories have been stamped on top, much like the carrying out of a computer program (Dreyfus, 1992). As we will soon discuss, this approach leads to a terminal plateau in their development that prevents them from reaching levels of expertise beyond competent. Nursing practice is a way of knowing in its own right, and provides the rich embedded and embodied know-how and is a well-spring for theorizing and theory development. Practice and theory are intertwined and mutually influencing, practice has embedded in it situational awareness, skilled know-how, and situated thinking-in-action. It is a socially organized and self-improving form of knowledge with constant discovery and experiential learning of its engaged, embodied, intelligent agents (Taylor (2016).
The outdated but common and popularized “Cartesian” (Rene Descartes (1637; 2016; Benner, 2021) view of the mind holds that concept, ideas, templates come first, and thus, are the causal source for all practical knowledge and understanding in the world, has been disproven in neuro-cognitive learning sciences (Alliball, &Nathan, 2018; Dreyfus & Taylor, 2015; Gallagher 2005; Van Gelder, 1995. Ennen 2003). Such a representational view of the mind and self, prevents us from noticing the perceptual and embodied skilled know-how that occur with being engaged, embodied agents learning directly from the world (Dreyfus & Taylor, 2016; Taylor, 2016). We lose connection with the radical changes in our understanding and skilled know-how as we enter a new practice world, where we experientially learn over time new ways of understanding and acting in situations, new ways of being in the world, new ways of experiencing meanings, qualitative distinctions, and nuances we come to perceive and understand better in the world through experiential learning. We also experientially learn over time, a sense of salience of what is most and least important and meaningful in particular clinical situations.
We lack public articulation and discussion of clinical experiential learning across time, what it entails, what new perceptions, perspectives and ways of acting are made possible by direct experiential learning from immersion in the real world of practice. We are also hampered in our understanding of expertise by a lack of public language or accounts of expert thinking-in-action, situational awareness (Endsley, 2018) and rapid clinical reasoning across time. Nursing knowledge is almost always presented as “knowing that and about,” and almost never as “knowing how and when,” nor is performative knowledge such as rapid clinical decision making or situated thinking-in-action often described nor accounted for. To counter this, I we encourage the use of first-person-experience-near-narratives (Geertz, 1987) of clinical reasoning across time as a way of capturing expert and masterful practice, “Knowing how and when,” situated thinking-in-action, situational awareness and rapid clinical reasoning in clinical crises.
Descartes (1637; 2016) experienced himself and others as separate, atomistic, private subjective selves that stood over against, and separate from the world. For Descartes, the mind was separate from the body, and world. This starting place in the imagination of the self, fails to notice that most often persons are engaged with others, and that they are actively involved in projects, most often, using embodied skilled-know-how, and embodied orientations to the world (Todes, S. 2001; Dreyfus, HL, 2017; Dreyfus, H.L. 1988) and actively engaged in concerns rather than being disengaged private separate subjects. And unfortunately, in a caring practice, this starting place for imagining the self as separate private, atomistic, person separated from body, world, not actively engaged and involved with people, concerns, or projects, leads to distortions. It overlooks knowledge, skills embedded in practice and misunderstands the situated possibilities of caregiving practices altogether. It mistakes the most rudimentary and incomplete forms of practical reasoning (formalized scientific method protocols and the decontextualized reasoning of a decision tree) as advanced and ideal decision-making because it neglects the reality of situated thinking-in-action and performance requirements and capacities.
Van Gelder (1995) points out that Gilbert Ryle, (1949; 2009) and Martin Heidegger (1927; 1962) led in the critique of a Cartesian view of the mind:
This (anti-Cartesian) movement comprises at least three major components, all intimately interrelated. The first is a relocating of mind. The Cartesian tradition is mistaken in supposing that mind is an inner entity of any kind, whether mind-stuff, brain states, or whatever. Ontologically, mind is much more a matter of what we do within environmental and social possibilities and bounds. Twentieth-century anti-Cartesianism thus draws much of mind out, and in particular outside the skull. The second component is a reconceiving of our fundamental relationship to the world around us. In the Cartesian framework, the basic stance of mind toward the world is one of representing and thinking about it, with occasional, peripheral, causal interaction via perception and action…. Escaping these epistemological problems means reconceiving the human agent as essentially embedded in, and skillfully coping with, a changing world; and that representing and thinking about the world is secondary to and dependent upon such embeddedness. …A fundamental Cartesian mistake is, as Ryle (2009) variously put it, to suppose that practice is accounted for by theory; that knowledge somehow is explained in terms of ‘knowledge that’ [knowing that]; or that skill is a matter of thought. That is, not only is mind not to be found wholly inside the skull; cognition, the inner causal underpinning of mind, is not to be explained in terms of the basic entities of the Cartesian conception of mind (Van Gelder. 1995, P.380).
This shift in understanding how the mind works and the various ways our immersion directly in the world creates learning (Taylor, 2016) can help the new practitioner better understand and cope with learning a new practice. A maxim in the video is that the Novice and Advanced Beginner senior nursing student and new graduate nurse can be the best most motivated and talented learner, but they cannot, as human beings, be beyond experience. Experience, in the Dreyfus and Dreyfus Model, always generates new understanding, nuances, qualitative distinctions, or even a radical changing of pre-understandings and pre-conceptions, perspectives (Dreyfus & Dreyfus, 1988; Gadamer, 1975). In examining learning a new practice, it is essential to first understand the nature of a practice. A practice is a socially organized, socially embedded form of knowledge and knowing that has distinctions of worth, values and notions of good internal to the practice. A practice calls for practical reasoning, or reasoning rooted in the contexts and knowledge of the practice and responsible agents carrying out the practice. In nursing, we call this “clinical reasoning.” Clinical Reasoning is a science using form of reasoning by a responsible, embodied, intelligent nurse who seeks to act responsibly in making sense of a clinical situation across time. In doing so, they come to a better, clearer, more accurate understanding of the situation through actively problem solving and exploring the transitions in the situation across time (Taylor 2016) and “thinking backwards,” if necessary. Thinking backwards is a form of Modus Operandi thinking to figure out what caused a particular cascade of clinical changes that created the patient’s current clinical condition so that root causes of clinical changes can be identified. Clinical reasoning uses science but is not a linear scientific problem-solving process that seeks to reach absolute judgments at particular points in time. Instead, it uses scientific knowledge combined with an understanding of the ethical and practical concerns in the particular clinical situation to make decisions that benefit the patient and families. It is always context dependent and cannot be well captured by formalized protocols, particularly protocols designed to deal with simple, problems with single causes. While formalized protocols are indispensable for novice, advanced beginner and competent nurses, eventually an understanding of the patient’s unfolding particular clinical situation begins to guide decision making, allowing nurses to question protocols when the individual patient’s clinical situation and science point to the need to do so.
Sullivan & Rosin (2008) call for a new agenda in higher education that moves beyond critical thinking alone, one that also prepares student’s for learning a practice:
…Teaching for practical reasoning is concerned with the formation of a particular kind of person—one who is disposed toward questioning and criticizing for the sake of more informed and responsible engagement. Such persons use critique in order to act responsibly, as it is the common search for ways to realize valuable purposes and ideals that guides their reasoning. Practical reason grounds the academy’s great achievement —critical rationality—in human purposes that are wider and deeper than criticism…In the end, practical reason values embodied responsibility as the resourceful blending of critical intelligence and moral commitment (Sullivan & Rosin, p. xvi, 2008).
In our study of nurses who had 20 or more years of experience, but who were not considered to be preceptors, nor give clinical opinions about difficult, complex clinical situations, we found that these nurses thought of their nursing work, not as a practice with internal notions of good and distinctions of worth that require attentiveness and adherence, but rather as “cause and effect” and scientific reasoning apart from practical engaged reasoning. As Jane Rubin, who led the analysis of the research on these nurses stated:
As Jane Rubin, (1996; 2009) writes:
I suggested that the structure of the practice of the nurses in this group is responsible for the inadequacies of the care they provide. If this is the case, the general form of the remedy for these inadequacies is clear. Whatever the psychological difficulties or moral shortcomings of these nurses, their fundamental problem is their lack of knowledge of the qualitative distinctions that are embodied in expert nursing practice. As we have seen, these nurses are at least somewhat aware of this problem. Their awareness manifests itself in their wish to make a difference and to have a genuine sense of agency. The solution to this problem, then would seem to be neither psychotherapy nor ethics courses—important as these are in other contexts—but a form of nursing education that is governed by the goal of improving clinical and ethical judgment by focusing on the goods specific to nursing practice and the skills that allows nurses to achieve them (Rubin, 2009 p. 197).”
Learning a new practice requires attentiveness, openness, responsiveness, and being able to be turned around in one’s thinking, when things do match up to one’s expectations and concerns. Descartes’ disengagement is a poor starting place for an engaged clinical reasoning and caring practice such as nursing where people’s concerns and lifeworlds matter, in addition to whatever illness or injury condition that they are experiencing. As nurses, we cannot afford to be disengaged nor can we expect success and professional growth with inadequate skills of involvement (Benner, Hooper-Kyriakidis & Stannard, 1999; 2011). Authentic caring and skills of involvement are essential for experientially developing clinical knowledge and skilled know-how and are central to all learning. In our studies of skill acquisition, we found that nurses who lacked good skills of engagement with both the patient/family and their problems (both patient and problem engagement), did not become expert nurses (Rubin, 1996; 2009; Benner, Hooper-Kyriakidis, Stannard, 1999; 2011).
Research-Based Narratives for the Dreyfus and Dreyfus Model of Skill Acquisition
In the video on the Dreyfus and Dreyfus Model of Skill Acquisition, We were not able to include the research-based narrative examples of each stage of the Model due to time constraints, so we selectively add them here and encourage you to read all the research narratives related to each Stage of the Dreyfus Model of Skill Acquisition in the book Expertise in Nursing Practice: Caring, Clinical Judgment and Ethics (Benner, Tanner, Chesla, 2010).
Our interpretive phenomenological research design required that we have nurses in small groups present first-person-experience narratives of their own clinical experiences. The participants were grouped according to years in practice. In each group there were two research interviewers, and we had the interviews transcribed prior to the next research meeting, so we could clarify anything that we did not understand in the nurses’ narratives. In addition to these small group interviews we observed and conducted brief interviews for clarification of the nurses’ actions and decisions of a sub-sample of all nurses in the small group interviews (See Benner, Tanner. Chesla, 2010 for a full description of the research methods.) Below, we augment the video with characteristics of the performance of nurses at each of the stages of skill acquisition, using the narrative excerpts from these small group narrative interviews starting with Advanced Beginner narratives.
Advanced Beginner Stage
The senior nursing student and newly graduated nurse are typically at the Advanced Beginner Stage.
“I think it is hard sometimes because you don’t recognize the obvious answer. ‘Just intubate the child.’ But then there are so many other parts of it that other people who have more knowledge are able to look at and say, “Yes, but this might happen and that might happen.” Then you really have to weigh the differences. And I’m not real comfortable with it. It is really easy to think you know what’s best, and in reality, there’s a whole realm of things that are going on that you are really not understanding.”
This Advanced Beginner, has an increasing awareness of the complexity of clinical situations and his or her lack of experiential knowledge. She has not yet seen enough of the futures of particular clinical decisions, nor is yet fully aware of the trade-offs in many clinical interventions, such as intubation. She wisely relies on the judgment of more experienced, expert nurses, as she awaits the time when he or she has lived through many patients’ trajectories and futures to better understand clinical trade-offs.
The following conversation between two Advanced Beginners further exemplifies their struggles with many practice situations that they have not yet had the opportunity to witness, nor fully understand.
Nurse 1: “I think what’s stressful is the expectation on us to be good all the time, and have all that knowledge right now.
Nurse 2: Right. Because it is not just one system that is failing. And these patients get real critical when everything is going on, and you have to think about everything that could possibly go wrong. And everything is going wrong. And it’s like the knowledge should be there, and where is it? And it’s not. And if it is there, it is in the notes, but you still have to read it, and you don’t have time right now to get out that piece of paper say: ‘Okay, dig toxicity. This is what I should look for, and this is what I should do.’
These Advanced Beginners trust that if they can call to mind the appropriate knowledge, their task is to systematically apply that knowledge to the problem at hand. Most cannot yet appreciate the under-determined changing nature of clinical problems, nor can they notice the many aspects of nursing practice that are not contained in unit protocols and procedures
The clinical situation shows up for them as a clinical puzzle requiring the application of the “right” knowledge and the “right” procedures and techniques of care. They suggest that part of their work is in recognizing which situation calls for what knowledge or procedures (Benner, Tanner, Chesla, 2009, pp. 32-33).
It is tempting for nurse educators to teach novices, in the first year of nursing school, and Advanced Beginners, in their senior year and first positions as professional nurses, that nursing practice can be reduced to narrow rational-technical application of well-worked out solutions for static simple clinical situations, ignoring typical co-morbidities and complicating treatment interactions and possible patient sensitivities, but such promised certainty and over-simplification hinders learning for the nurse entering a complex practice such as nursing, and creates false expectations for Advanced Beginning Nurses.. The following rapidly changing clinical crisis as described by a new graduate nurse caring for a patient who was being worked-up to rule out sepsis: The situation is fraught with unknowns and chaos:
Advanced Beginner: So I kind of felt bad at the start because I didn’t know what was going on with this patient. I felt that something must be going on with her, and I didn’t know about that…They came in, about three doctors and started giving orders. And I was trying to assimilate all the things that they wanted me to do and prioritize the best I could in the situation. And I just felt real irritated, because I wasn’t doing a good job, and nothing I did pleased them even though I was working really hard. And my nursing supervisor was in there working too. …My supervisor would make comments like: “Now, you remember your main concern tonight is her respiratory system.” It was like, ‘I think that’s pretty basic and knew that her oxygen saturations were dropping, and that was a concern of mine.” …
Interviewer: “She was in Septic Shock and you didn’t know it at the time?”
Advanced Beginner: ”Well, they suspected that it might be but it turned out that she wasn’t . She just had some biliary sludging.
Interviewer: So, at the time, did you feel that you understood why you were doing the things that you had to do?
Advanced Beginner: No not at all. Not at all. Had no idea. I made a comment to one of the doctors . “It’d sure be nice for me to know what I am doing all this stuff for.” And then the doctor would give me orders and obviously, I hadn’t prioritized the way that she had prioritized, and I really resented her for days. And so I feel like just one night can really destroy my ego for a week….It just seemed like nothing went right basically, except that the patient lived. And she was fine.
This exemplar illustrates how Advanced Beginners must work in clinical situations where they lack even a minimal grasp of the patient’s condition. …What is unfortunate is the lack of opportunity to discuss the situation with the team involved to gain some perspective on her accomplishments.
A nurse preceptor could have made all the difference in this rapidly evolving clinical situation, making it a potential learning situation rather than a situation riddled with defeat and failure for the Advanced Beginner.
The competency level is a time of increased organizational skills and also sense of accomplishment. The competent nurse is at risk for leaving during this time, thinking that many of the aspects of her work will be improved by a new work environment. But without accomplishing the particular demands inherent in the style of work during the competency stage, the nurse will have to confront and repeat limits to style of work at the competent stage in a new work environment: “Organization now comes to mean not just completing tasks on time, but anticipatory planning for rapidly changing non-routine events, preparing an environment, having the appropriate equipment and resources at hand, and performing calmly and efficiently (Benner, Tanner, & Chesla, 2009, p. 64).” The competent level nurse learns experientially how impactful her clinical understanding and reasoning are to the patient’s well-being: “The competent nurse’s sense of agency is related to what she can plan, predict and control (Benner, Tanner, Chesla, p.78).” Competent level nurses are increasingly aware of what they need to know and what they have not yet mastered:
Nurse 1: Today we are required to know so much, and it is like our role is kind of overshadowing the doctors’ because we are there we’re taking on their responsibility. You have done so much. And you have probably even done beyond what you are required to do because your knowledge base is so extensive. You’ve read at home or you have researched something that you are interested in so you are a little bit more knowledgeable about something. But then this is just for me, personally, I go home and I think, “Oh God, what else could I have done? Maybe if I knew a little better, I could have done that…It’s like today you are required to know so much. You get into situations where patients are so sick, if something happens where maybe that one little thing you didn’t think about [occurs] it’s like the guilt and fear you have during that time is just unreal. And you go home and you have to deal with that, and you know that puts a lot on you.
Nurse 2: You make a mistake and you can’t erase it.
Nurse 1: You can’t just leave and go to lunch.
Nurse 2: And you can’t take it out of the computer. I mean that’s somebody’s life. I mean you are dealing with life, and you are dealing with death, and a lot of professions don’t have that.
The competent stage is a time of questioning, and conflict because of the inherent demands of nursing practice, and the lack good articulation of what nurses must know and the level of demands for rapid clinical reasoning and Situational Awareness (Endsley 2018) during patient crises:
There is a qualitative leap in the way that work is organized and the style of practice with proficiency. Practice becomes much more attuned to the situation. Where the competent nurse is busy organizing, planning and managing the situation, the proficient nurse listens to the situation, and often changes her perspective on the situation. The narratives are often about being turned around in one’s perceptions. Nurses frequently made statements such as: “I went into the situation thinking ‘this is what was going on,’ but, that wasn’t what was actually going on.” This ability to read the situation and have one’s perspective on the situation change, improves clinical understanding along with increasing one’s ability to respond to the situation:
The shift from competent to proficient performance is dramatic, marked by a qualitative change in what the practitioner is able to see. Proficient performance is characterized by an increased capacity for recognizing… salience where relevant aspects of the situation simply stand out without recourse to calculative reasoning. Proficient practitioners can read a situation, recognizing changing relevance, and, accordingly, shift theirperspective on the whole situation (Benner, Tanner, Chesla, 1996; p. 142).
Aa Dreyfus noted:
We did not recognize the importance of proficiency when we originally developed the five-stage model. And, indeed, up to stage 4 nothing new or controversial occurs, but within stage 4, which we call “Proficiency,” there is an important new development. The student must be able to give up on an analytical and thoughtful stance toward the situation and accept experiential learning. Stage 2 involved using features that could not be precisely defined but could only be recognized through experience. At stage 4 the student begins to recognize whole types of situations in a skill domain. This recognition has been called “making sense of the situation (Dreyfus, 2017, p. 149).
It is this shift to proficiency that awaits the often conflicted and frustrated competent level nurse if they do not leave the field. If competent level nurses avoid leaving their first job until they have reached the proficient stage, they will progress more smoothly to proficiency without the disruption of learning a new work environment and new system of care delivery.
Proficient Nurse: I had drawn a blood gas on a person and it was pretty poor. And I took another blood gas. And the house officer looked at it and said: “I don’t believe this gas. This patient hasn’t changed.” And at that point, it takes awhile to get to this point, I felt comfortable in saying to him: “What do you mean, this patient hasn’t changed. This patient’s blood pressure has gone up to 200,” And I presented him with a picture of this patient that he had obviously overlooked…
Interviewer: What happened in that situation?
Nurse: I was right.
Interviewer: But what led you to believe that the gas was correct?
Nurse: Well there were a lot of objective things. This patient had been in a pentobarbitol coma for a few days, and they had just discontinued it that day. The nurse who gave report said: “Oh, he won’t wake up tonight.” But, of course, he did. And his respiratory rate was 36. He was breathing 24 over his vented breaths. His blood pressure had gone up from 120 to 200 over a period of 3 hours. There was just a look about him that just wasn’t the same. You could look at him and tell that he had changed drastically in the last 5 or 6 hours.
Interviewer: How did you learn that the objective signs that you were seeing were correlated to the blood gasses?
Nurse: Just experience, and seeing different patients and different breathing patterns and knowing by looking at the at the patient that this breathing pattern is effective and this one isn’t. Knowing whether there is air exchange or not. These breaths aren’t effective and he is wearing himself out, and that could be the cause of the deterioration of his gas, and just experience and seeing different cases and how people adjust to physical things that are going on.
Although difficult to articulate, this practical grasp is not mystical. It reflects the skill of seeing practical manifestations of changed physiological states and patient responses as well as engaging in practical reasoning about these transitions.
The ethos of openness rather than prediction and control, and fidelity to what one sees and hears rather than excessive suggestibility and confusion are embodied and linked to one’s emotional responses to the situation (Benner, Tanner & Chesla, 2009, p. 107)
The proficient nurse engages in response-based practice, and organization of tasks typically follows what needs to be done in terms of urgency and priority:
Nurse 1: The residents don’t do transports very often. They are not used to doing as much as the nurse is doing, and the nurses work better together and get the baby spiffed up faster [resuscitated and stable].because we are used to do it and you just do what needs to be done. I was working on one new baby by myself and got the line in. And he was working on the other baby and put the line in. …
Nurse 2: Everybody has a specialized role, and you just kind of go back and forth, and there’s a camaraderie.
“Just doing what needs to be done,” is a skilled response based on knowing how and when (Benner, Tanner, Chesla, 2009, p. 112).”
In the following proficient nurse narrative, her perspective on the patient changes rapidly as his condition changes:
We admitted a patient who became very sick very quickly. He had a huge infarct. After about two hours after he was admitted, he vomited and obviously had aspirated his vomitus. He was hypoxic. He was blue and crawling off the stretcher. He was a huge man and I said to the intern, “You need to draw a blood gas.” And he said, “I drew one when he came in.” I looked at him and threw the blood gas syringe at him. His P02 was 30 or something like that. He had to be intubated. I said the situation changes often, and you can’t say, “I drew one.” I said look at him. Take a gander. Does he look like the same patient you drew a blood gas on? He just didn’t know what to do.
Here, the proficient nurse recognizes a change in the situation and the intern is not responding to the change. While hypoxia seems obvious from the description, the intern probably little practical experience with such rapid changes, and in the urgency of the situation, he probably had little sense of the passage of time. Learning about the actualities of clinical change is a good example of experientially-based clinical knowledge. Any one of these clinicians would have been able to answer a formal test question about the possibility of a blood gas changing within an hour and correctly identify conditions under which oxygenation changes rapidly, so it is not “factual” knowledge that is at stake here. Rather, recognition of salient facts and orchestration of skilled responses within the time demands of the situation constitute the relevant knowledge and skill (Benner, Tanner, Chesla, 2010, p. 113).
These proficient nurses’ narratives reveal the attunement, and deep background understanding of the nature of the clinical situation that develops in this qualitatively distinctly different style and ways of being in the situation for the proficient level nurse.
As Dreyfus pointed out when comparing human expertise to computerized capacities, the human expert can respond in a way that is as orderly as the situation demands (Dreyfus, 1992)
In high time demand of a clinical emergency, increased perceptual acuity and skilled know-how help the nurse to respond to the situation in a fluid nonreflective way. The skilled actions are themselves a way of “thinking” because the actor is responding to experientially learned distinctions and timing. When the nurse talks about taking her time, she is probably talking about a process lasting less than a minute, which during a resuscitation can seem like a very long (Benner, Tanner, Chesla, 2010, p. 112).
Expertise represents a deepening and extension of the gains in changing their perspective in a clinical situation. With Expertise comes increased situational awareness and improved thinking-in-action, and more adept changes in perspectives. A flexible recognition of changes in deeply familiar clinical situations now occurs as illustrated in preparing an critically ill infant for an air transport:
It was good that there were two of us nurses, who were both senior. The kid’s right lung was down and the doctor was able to get the chest tube in, but wasn’t getting any air back. We listened and there were no breath sounds so it was going through the process as fast as you can and try to think of what’s wrong. We had a tube in one side, and there were just minimal breath sounds, and it went to nothing so one person started suctioning and got a mucous plug out. And I tried inserting a needle in one side of the chest but couldn’t get any air out. Then while I was doing that the pediatrician pulled out the one chest tube that he had put in and the kid had no breath sounds on that side again, so we were bagging him. We started having better breath sounds on one side, so I put a chest tube in the other side. (The story continues with much trouble shooting and response before and after the transport concludes with a report that the child is now a healthy 2 -year- old with no brain damage).
This is a good example of the patient response-based practice of expert nurses deeply familiar with the clinical situation. In active descriptions of triage, and in rapidly moving sports situations we get such action-oriented accounts, but they are almost absent in medical and nursing actions during a rapidly changing clinical situation so we underestimate the knowledge of the expert capable of rapid clinical reasoning in fast-paced, under-determined clinical situations. Bourdieu (1990. P.103) points out that academics studying sports, for example, in rugby give credit to the relationship between team members without studying the more impactful role of the actions of the opposing team for creating the team’s moves on the field in the midst of the game.
Because of their perceptual acuity, the expert is often able to give an early warning of impending dire changes in a patient’s condition as evident in the following expert narrative:
Expert Nurse: I was taking care of a baby with a complex heart disease who had a shunt placed and had been extubated earlier that day. Around midnight, he started to get a little more pale…his lung sounds were okay. They had a few crackles, but nothing significant. And by 2:00 AM, he was looking quite a bit worse, and his lungs were very wet, which is like he was dumping fluid into his lungs. … I just decided to try to get as much information on this baby before I went and got the doctor up, because this doctor tended to be less likely to take action. So, I got a blood gas and the pH was 7.2. The blood gas was very low, but the PC02 was 55.., The baby’s neck veins were distended. So, I went and got the doctor up and told her what the baby looked like. She came over and listened to the baby’s lungs and said there is no fluid in that kid’s lungs. It’s just the stethoscope rubbing up against the chest wall. And I said, “It doesn’t sound like that to me. And I said, “I didn’t hear this at midnight, and I am hearing it now.” She said, “That is not fluid. That baby is dry.” …And requested that we could give him some bicarbonate and Lasix, and she agreed to the bicarbonate, but refused the Lasix, saying that the baby’s lungs were dry. Then she said, “Well let’s go ahead and get a chest film… and you can see for yourself.”….Xray called back and said its awful. The baby’s lungs are terrible.” They were completely whited out. [The doctor still did not believe that the baby’s lungs were wet and called the attending, who ordered Lasix]…I looked at the baby and he looked much worse than he had before.
Interviewer: How did he look much worse to you?
Expert Nurse: His mouth was just open slightly. He was just gasping to breathe. He just looked awful, looked absolutely terrible, and so I asked the doctor if I could go ahead and get another blood gas. And she came out from talking to the other doctor and said,” Have you given Lasix yet?” and I said, “You haven’t ordered it.” And so she said, “Go ahead and give Lasix.” So the doctor did tell me that she called at home and the doctor said that he wanted some Lasix, so I gave the Lasix, but at that point the baby was looking so bad that I didn’t even wait for the Lasix to take effect before I went ahead and did another blood gas without the resident’s order and the pH by this time was 6.74 and his C02 was 155, and so we had started bagging the baby before I got the results of the gas back just because thC02 was so high and the baby’s saturations were dropping by this point so that we intubated the baby, and then by this point I think the doctor realized that she had made a mistake in being a little less willing to take charge and to go ahead and do things for the baby instead of waiting for the baby to pull himself out of it, which he was obviously not going to do So she went ahead and ordered the [ventilator] pressures to be given pretty high and the rate turned up to 80 and within minutes, the baby had started to pick up. His eyes were open. He was looking around and just got better and I guess three days ago he got to go home.
In the end this expert nurse and resident were able to work together for the good of the patient. The expert nurse does not deny her clinical judgments and stays firm in getting what this infant needs. It is fortunate that the physician ordered the chest film which clarified the baby’s clinical condition.
This expert nurse is well grounded in her clinical reasoning. She also has other nurses in the unit listen to the baby’s lungs and agree that they were “wet.” The nurse compares what she heard when listening to the baby’s lungs at midnight and was clear about the changes across time. This situation does not get derailed by the clinical disagreement between the nurse’s appraisal and the physician’s appraisal, and the situation is helped when the expert nurse stays firm in her clinical findings. This is an experienced-based authoritative appraisal, so the nurse does not waiver in her clarity about her clinical judgment about the baby’s lungs sounding wet. This kind of authoritative clinical judgment is more than assertiveness, it is the expert nurse being a responsible agent willing to take a stand for the good of the patient.
Mastery 1 and Mastery 2
We did not study mastery in our nursing studies of the Dreyfus model because it was not yet discovered and described. In 2009, H.L. Dreyfus states about the Mastery 1 and 2 levels of competency:
…When an expert learns, she must either create a new perspective in a situation when a learned perspective has failed, or improve the action guided by a particular intuitive perspective when the intuitive action proves inadequate. A master will not only continue to do this, but will also, in situations where she is already capable of what is considered adequate expert performance will be open to a new intuitive perspective accompanying action that will lead to performance that exceeds conventional expertise. Thus, although producing a higher level of skill than the expert, the brain of the master doesn’t use any operating principles (Dreyfus, 2009, Kindle Location 786)
While we did not study Mastery 1 and 2 in nursing, but we could identify very innovative situations that would qualify as being beyond expertise. This is a ripe area for study because it can enlarge understanding and descriptions of innovations in practice that go beyond expert practice:
…We observed and interviewed a nurse in an intensive care unit (Benner, Tanner, Chesla, 2009) who started a tailored approach to care for dying patients in the ICU when there was no possibility of transferring a patient to a quieter place for hospice-type palliative care. This nurse created as much privacy as possible in her ICU, allowing family members to gather at the bedside and altering the usual unit visiting practices. She encouraged loved ones who wanted to embrace and lie with their loved ones to join them in the bed and introduced many more comfort measures not usually practiced in the ICU environment. Another nurse provided guided imagery for a patient with cancer, who wanted to go home but lacked an adequate white cell count to be safe. This guided imagery and other relaxation strategies instituted by the nurse improved the patient’s immune system enough to be discharged home. It is an open question as to the extent to which mastery can be facilitated in practice. Indeed, an environment open to innovation is a minimal requirement. Like expert practice, studying and articulating innovation at the mastery level can help stimulate and extend innovation in practice, and identify innovations ripe for evaluation and extension through research. Identifying mastery level performance probably facilitates imagination and motivation to go beyond expertise (Benner, 2021).
No doubt Nurses who are at Mastery Levels 1 and 2 exist in nursing and medical practice, but their practice has not been studied. Expert nurses’ practice is inadequately studied despite the frontline knowledge of expert nurses (Benner, Tanner, Chesla, 1996; 2009). Hospitals are high-risk complex organizations that are only beginning re-think their organizational design based upon the research on High Reliability Organizations (Weick & Sutcliffe, 2015; Hays, 2013).
Studying the innovations of nurses at the Mastery 1 and 2 levels couldn’t come at a better time, than this time of critical shortage of nurses. Many hospitals are forced to use nurse extenders during this critical nursing shortage. But the design for use of nurse extenders must match the ongoing demand for professional nurses’ close monitoring of acutely ill patients who require instantaneous therapies and instantaneous corrections in their intravenous therapies. The change in the care of the acutely ill patients to instantaneous interventions in hemodynamics and cardiac arrhythmias, impending shock, sepsis and more began in the early 70’s and has just kept increasing since. Delegating astute monitoring of patients by nursing assistants and Licensed Vocational nurses creates high risks for decreasing patient safety and quality of care due to fewer “early warnings” of changes in patients and increased failure to rescue. Patient’s safety and lives are not fungible. Hospital organizational design needs to be close to and learn from frontline expert care. Designs following HRO’s would increase the likelihood of better understanding and visibility of the frontline expert nurse’s and physician’s rapid clinical decision making, situated thinking-in-action and Situational Awareness.
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