Patricia Benner "The Primacy of Caring Model" (From Novice to Expert Nursing Model)

"Nursing is an integrative science that studies the relationships between mind, body, and human
worlds. It is concerned with far more than the cognitive structure of formal mental properties, such as
attitudes and belief systems of the mind-brain, and the physiology and pathophysiology of the body as a
system of cells, tissues, and organs. Nursing is concerned with the social sensient body that dwells infinite
human worlds: that gets sick and recovers; that is altered during illness, pain, and suffering; and that
engages with the world differently upon recovery"

Patricia Benner (1984, 1989)

Caring is central to human expertise, to curing, and to healing. Persons, events, projects and things
matter to people. Caring is primary for the following reasons:
a. What matters to people sets up not only what counts as stressful but also what options are
available for coping.
b. It enables a person to notice salient aspects of a particular situation, to discern problems, and to
recognize potential solutions.
c. It sets up possibilities for giving and receiving help.

History and Background

Patricia Benner is a Professor in the Department of Physiological Nursing in the School of Nursing
at the University of California, San Francisco. Dr. Benner received her bachelor's degree in nursing from
Pasadena College, her master's degree in medical surgical nursing from the University of California, San
Francisco, and the Ph.D. from the University of California, Berkeley, in Stress and Coping and Health under
the direction of Hubert Dreyfus and Richard Lazarus.
Dr. Benner is the author of nine books including From Novice to Expert, named an American
Journal of Nursing Book of the Year for nursing education and nursing research in 1984, and The Primacy
of Caring, co-authored with Judith Wrubel, named Book of the Year in 1990, also in two categories. Her
books have been translated into eight languages. Her most recent books are: Interpretative
Phenomenology: Embodiment, Caring and Ethics in Health and Illness, and The Crisis of Care, with Susan
Philips, both published in 1994, Expertise in Nursing Practice: Caring, Clinical Judgment, and Ethics, with
Christine Tanner and Catherine Chesla, also named a Book of the Year in 1996, and Caregiving, with
Suzanne Gordon and Nel Noddings, also published in 1996. Published in December, 1998, is Clinical
Wisdom and Interventions in Critical Care: A Thinking-In Action Approach, with Pat Hooper-Kyriakidis and
Daphne Stannard (W.B. Saunders)
Dr. Benner is an internationally noted researcher and lecturer on health, stress and coping, skill
acquisition and ethics. Her work has had wide influence on nursing both in the United States and
internationally, for example in providing the basis for new legislation and design for nursing practice and
education for three states in Australia. She was recently elected an honorary fellow of the Royal College of
Nursing. Her work has influence beyond nursing in the areas of clinical practice and clinical ethics.
She has been a staff nurse in the areas of medical-surgical, emergency room, coronary care,
intensive care units and home care. Currently, her research includes the study of nursing practice in
intensive care units and nursing ethics.

Overview of Patricia Benner's Philosophy in Nursing

Benner proposed seven domains of nursing practice which are as follows:
1. The helping role.
2. The teaching-coaching function.
3. The diagnostic and patient-monitoring function.
4. Effective management of rapidly changing situations.
5. Administering and monitoring therapeutic interventions and regimens.
6. Monitoring and ensuring the quality of health care practices
7. Organizational and work-role competencies.
 Benner's Domains of Nursing Practice
1. The Helping Role Domain
•This includes competencies related to establishing a healing relationship, providing comfort
measures, and inviting active patient participation and control in care.
2. The Teaching-Coaching Function Domain
•This includes timing, readying patients for learning, motivating, change, assisting with lifestyle
alterations, and negotiating agreement on goals.
3. The Diagnostic and Patient-Monitoring Function Domain
•This refers to competencies in ongoing assessment and anticipation of outcomes.
4. The Effective Management of Rapidly Changing Situations Domain
•This includes the ability to contingently match demands with resources and to assess and manage
care during crisis situations.
5. The administering and Monitoring Therapeutic Interventions and Regimens Domain
• This includes competencies related to preventing complications during drug therapy, wound
management and hospitalization.
6. The Monitoring and Ensuring the Quality of Health Care Practices Domain
• This includes competencies with regard to maintenance of safety, continuous quality
improvement, collaborative and consultation with physicians, self-evaluation, and management of
technology.
7. The Organizational and Work-Role Competencies Domain
•This includes competencies in priority setting, team building, coordinating, and providing for
continuity. According to Benner, clinical nursing requires theoretical knowledge and practical knowledge.
Theoretical knowledge can be acquired in an abstract fashion through reading, observing or discussing. On
the other hand, the development of practical knowledge requires actual experience in a situation because it
is contextual and transactional.

ASPECTS DEFINITION EXAMPLES

Qualitative Perceptual, recognitional clinical Discrete, alterations in skin color Meanings of
distinctions judgment that refers to accurate changes in mood.
detection of a minute alterations that Different manifestation of anxiety
cannot be qualified and that are often
context dependent.
Maxims Cryptic statements that guide action and When you hear hoof beats in Kansas, think
require deep situational understanding horses , not zebras. Follow the body’s lead.
to make sense.
Assumptions, Knowledge from past experience that Assumptions include the ability to maintain
expectations, helps orient and provide a frame of and communicate hope in situations based on
and sets reference for anticipatory guidance possibilities learned from previous similar
along the typical trajectory. situation.
Assumptions are often taken for It is expected that an obese person with
granted, tacit beliefs that something is
essential hypertension who engages loses
true. Expectations are notions that weight in aerobic exercise 3 times a week will
something can be reasonably anticipated
experience a decrease in blood pressure.
following a certain scenario. A set can be illustrated by thinking about the
Sets are inclination or tendencies to difference in the way a nurse would approach
respond to anticipated situations. a woman in labor for whom everything
seemed to being normally and the way a
nurse would approached the woman if there
was a known fetal demise.
Common Shared, taken for granted, background It is often better to know even bad news than
meanings knowledge of a cultural group that is not to know.
transmitted in implicit ways
Paradigm Cases Clinical experiences that stand out in The first patient a nurse worked with who
one’s memory as having made a stops smoking.
significant impact on the nurse’s future The first patient with a breast lump whom a
practice and profoundly alter nurse refers for evaluation.
perceptions and future understanding.
Exemplars Robust clinical examples that convey Helping a patient/family to experience a
more than one intent, meaning, or peaceful death.
outcome and can be readily translated Teaching/coaching a patient/family to live
to other clinical situations that maybe with a chronic illness.
quite different. An exemplar might
constitute a paradigm case for a nurse
depending on its impact on personal
knowledge and future practice
Unplanned Knowledge that develops as the practice Experience gained with available alternative
Practice of nursing expands to new areas therapies and patient responses to them

In this interpretative phenomenological perspective, the body is indispensable for intelligent behavior
rather than getting in the way of thinking and reasoning. According to Dreyfus (1992), the following are
three areas that underlie all intelligent behavior:
1. The role of the body in organizing and unifying our experience of objects.
2. The role of situation in providing a background against which behavior can be orderly without being
rule-like.
3. The role of human purposes and needs in organizing the situation so that objects are recognized as
relevant and accessible.

•Interpreting kinds of pain and selecting appropriate strategies for pain management and pain control.
•Providing comfort and communication through touch providing providing emotional and informational
support to patient’s families
•Maximizing the family's role in care.
•Normalizing the situation.
• Managing frustrations when limited options constrain the ability to help.
• Participating in significant intimate life events. Healing through communicating.

■Domain: Organization and Work-role Competencies

Areas of Skilled Practice
•Coordinating, ordering, and meeting multiple patient needs and requests: Setting priorities.
•Orchestrating the whole situation, contingency management.
•Providing for continuity and discharge planning.
•Building and maintaining a therapeutic team to provide optimum therapy, conflict management.
•Coping with staff shortages and high turnover.
✓ Contingency planning.
✔Anticipating and preventing periods of extreme work overload.
✔Using and maintaining team spirit: gaining social support from other nurses.
✓ Maintaining a caring attitude toward patients even in absence of close and frequent contact.
• Making the bureaucracy respond to patients' and families' needs.
•Coaching other nurses; role-modeling.

■Domain: Administering and monitoring Therapeutic Interventions and Regimens

Areas of Skilled Practice
•Starting and maintaining intravenous therapy with minimal risks and complications.
•Administering medications accurately and safely: Monitoring untoward effects, reactions, therapeutic
responses, toxicity, and incompatibilities.
•Combating the hazards of immobility: Preventing and intervening with skin breakdown, ambulating and
exercising patients to maximize mobility and rehabilitation, preventing respiratory complications.
•Creating a wound management strategy that fosters healing, comfort, and appropriate drainage.

■Domain: Monitoring and Ensuring The Quality of Healthcare Practices

Areas of Skilled Practice
•Providing a back-up system to ensure safe medical and nursing care.
• Formulating own perspective on what should be done and using this as a yardstick for interpreting the
course of events.
• Maintaining environmental safety: attending to principles of asepsis, infection control, body mechanics,
and general safety.
• Participating in Continuous Quality Improvement monitoring and evaluation for safety, efficiency,
effectiveness and cost containment.
•Monitoring documentation for quality and accuracy.
• Assessing what can be safety omitted from or added to medical orders.
•Getting appropriate and timely responses from physicians.
•Using physician consultation effectively.
•Collaborative consultation-"Dr. shopping".
• Self-monitoring and seeking consultation as necessary.
•Giving constructive feedback to physicians and other care providers to ensure safe care practices.
•Critically evaluating and incorporating relevant research into practice.
•Managing technology, preventing unnecessary technological intrusions.

■Domain: The Teaching-Coaching Function of the Nurse

Areas of Skilled Practice
•Timing: Capturing a patient's readiness to learn.
•Motivating a patient to change.
•Assisting patients to integrate the implications of their illnesses and recovery into their lifestyles.
• Assisting patient to alter their lifestyles to meet changing healthcare needs and capacities: Teaching for
self-care.
•Eliciting an understanding of the patient's interpretation of his/her illness.
•Negotiating agreement about how to proceed when priorities of patient and provider conflict.
•Providing an interpretation of the patient's condition and giving a rationale for procedures.
•The coaching function: Making culturally avoided and uncharted health and illness experiences
approachable and understandable.
•Guiding a patient through emotional and developmental change.
•Providing new options, closing off old ones: Channeling, teaching, mediating:
✔Acting as a psychological and cultural mediator.
✓ Using goals therapeutically.
✔Working to build and maintain a therapeutic community.
•Debriefing with patient after rounds

■Domain: Effective Management of Rapidly Changing Situations

Areas of Skills Practice
•Skilled performance in extreme life-threatening emergencies: Rapid grasp of a problem.
•Contingency management: Rapid matching of demands in emergency situations.
• Identifying and managing a patient crisis until physician assistance is and resources available.

Adapted from Brykczynski, K.A. (1998). Clinical Exemplars Describing Expert staff Nursing Practice. Journal
of Nursing Management, 6, 354.
 Critical Thinking In Nursing Practice with Benner's Philosophy
Aspects of Clinical Judgment Definition and Skillful Comportment
Reasoning in Transition Practical Reasoning in an open clinical situation
Skilled Know-how Embodied intelligent performance, which involved knowing what
to do, when to do it, and how to do it
Response-based practice Adapting interventions to meet changing needs and expectations
of patients
Agency One’s sense of and ability to act upon or influence a situation
Perceptual acuity and involvement Adaptability to tune in to a situation and hone in on the salient
issues b engaging with the problems (s) and the person(s)
Links between clinical and ethical Understanding of goods clinical practice cannot be separated
reasoning from ethical notions of good outcomes for patients and families

Application of Patricia Benner's The Primacy of Caring Model

Case History of Mrs. Rubi Agua

Mrs. Rubi Agua is a 24 year old young woman from Bacolod who speaks Ilonggo and little Tagalog.
She had moved to Butuan City, the hometown of her husband Melchor. She was admitted in the Labor and
Delivery Department of Butuan Doctors Medical Center for the birth of her first baby. She was a full- term
primipara.

Mrs. Agua was transferred in the ICU because she became comatose secondary to acute fatty liver
of pregnancy following the delivery of her healthy baby girl. She was intubated, placed on a ventilator, and
required hemodialysis. Her electroencephalogram (EEG) showed minimal brain wave activity. She was
eventually designated a "do not resuscitate" (DNR) case after consultation with her husband and her
family.

In contrast to the physicians' hopeless prognosis for Mrs. Agua's recovery, the nurses remained
hopeful for possibilities of recovery in this extreme situation and they exerted concerted effort to put her
body in the best condition for healing. They provided stimulation in the environment such as playing soft
mellow music and songs of praise because they learned from her husband, Melchor that these are her
favorite music. They encouraged the family to talk to her, near her ear and whisper loving and encouraging
words, to touch her, hold her hands every now and then. The family spoke to her in Ilonggo, whenever
possible and placed her baby across her chest where she could hear her and feel her presence. They
provided her supportive care in cooperation with the supportive care provided by the nurses. The
supportive nursing care included providing nasogastric tube feedings, hygienic measures (bed bath, oral
care, perineal care, hair shampoo), frequent position changes, passive range-of-motion exercises, massage
of body parts especially bony prominences, change of gown and bedsheets as necessary, suctioning of
secretions from the mouth and endotracheal tube, care of the urinary catheter and the urinary bag,
providing protective devices to prevent contracture deformities such as footdrop, clawhand deformity, and
external rotation of the hips. The family also provided (in Ilonggo whenever possible) updates about her
baby and explanation of what was happening. The nurses also included the baby's father in their care.

A photo of Mrs. Agua and her baby, taken just before her discharge from the hospital that shows
her edematous jaundiced body, and another taken during a return visit to the hospital clinic that shows her
as a petite beautiful and fair-skinned woman are posted in the nurse's station. These photos serve as an
inspiration and as a reminder to nurses to be vigilant in recognizing situations where it may be imperative
to buy time while the body heals itself.
That patient deserves the best nursing care even in situations where recovery of the patient is
almost impossible.
Nursing Care of Mrs. Rubi Agua with Benner's Philosophy in Nursing Practice
 Domain: The Helping role
•The holistic view of the nurses enabled them to perceive Mrs. Agua's situation very differently from the
objective clinical gaze of the physicians. As one of the nurses narrated:

"Neuro team came in, and looked at her pupils, result of EEG, tested her reflexes-that was what they saw,
the nervous system and lack of neurologic function. GI team came in and they saw just the liver, the ascites,
and the jaundice. Renal team came in and saw signs and laboratory tests for poor kidney functions. OB
team came in and saw a comatose postpartum young woman. And many other teams came in and saw a
particular system in the body of this patient"

•This observation by the nurse reflects that the objective clinical gaze is depersonalizing and divides
the person into the separate organs and organ systems of interest to different specialties.
•The nurses were aware that Mrs. Agua was a young, healthy woman before developing this rare
pregnancy-induced illness, and they have perceived accurately to follow the lead of the patient's body
toward possible restoration of health.
• The nurses worked so hard to establish a healing environment for Mrs. Agua because no
postpartum woman had ever been declared a DNR in this ICU before. Having no experience with such a
situation, the nurses did what they had to do to maintain and support her so that her body could heal
itself---if that was to be. This is an example of the common meaning Benner (1984) calls "situated
possibility" in which nurses learn that even the most serious illness circumstance has its own possibility.
Knowing that the hormonal stress response associated with giving up hope can influence the course of an
illness (Benner, 1985a), the nurses never gave up hope nor did the family members. They stayed close by
and prayed for Mrs. Agua throughout her hospital stay. The power of prayer in influencing healing is
recently receiving more research attention as spirituality is becoming more widely recognized (Byrd 1997).
•The following two obvious aspects clearly affected the development of a collaborative relationship
between Mrs. Agua and her nurses:
1. Mrs. Agua was comatose and unable to communicate in any obvious way with the nurses caring
for her.
2. The majority of nurses spoke only Visayan and Tagalog and knew few, if any words in Ilonggo.

•In striving to create a healing climate for Mrs. Agua, the nurses realized that she probably could hear but
was unable to acknowledge this. For this reason, they spoke to her while they provided her care. They
spoke to her in Tagalog in slow manner, hoping to convey their feelings and concern by the tone of their
voices. The nurses reported that when Mrs. Agua returned to conscious state, she recognized those who
had cared for her by their voices.

 Domain: The Teaching-Coaching Function

•The nurses reported that they described what they were doing while they cared for Mrs. Agua and
consistently provided ongoing feedback about her condition and her family to promote her participation in
care as much as possible. They were involved with the father of the baby who was struggling with this very
difficult situation. The nurse reported:

"At times he would cry if he was holding the baby and not want to cry- especially being a Filipino male. We
encouraged him to hold the baby himself. We realized that this was not something he had planned on-in
Filipino culture, the woman is expected to help with the baby and integrate the baby into the household. It
was kind of like, "here's the baby," and it was really hard for him. He had a lot of mixed emotions. He was
so unsure of what he was going to do."
 •In coaching the father through this unexpected illness experience the nurses received much
support from another nurse who works in the Medical-Surgical Unit who was fluent in Ilonggo. This nurse
was frequently floated in the ICU to serve as interpreter.
 Domain: The Diagnostic and Monitoring Function
•Understanding the disease process and particular demands of Mrs. Agua's illness was crucial in
anticipating her care needs.
•The nurses reported reading everything they could find about Mrs. Auga's rare condition (acute fatty
liver of pregnancy) to increase their understanding of her illness and enhance their ability to assess her
potential for wellness and for responding to various treatment strategies.

 Domain: Administering and Monitoring Therapeutic Interventions Regimens

•In an effort to normalize the situation as much as possible the nurses continued to bring Mrs. Agua's
baby in to her and place the baby on her chest. The nurses played a tape of her baby's sounds as well
during her stay in the ICU.
•One of the nurses describes how bringing the baby in to the mother helped them as well as Mrs.
Agua:

"Part of it I think initially when we were bringing the baby in was it helped us in a way too because we
didn't want the baby staying in the nursery without really being nurtured for as long as her mother is
comatose."

•The nurses thought of consulting the physician to get an order of additional foods to be included in her
tube feedings - foods that support milk production. They also consulted with OB and pediatrician to allow
them to pump Mrs. Agua's breasts to maintain lactation because they are hoping that there will come a
time that she may be allowed to breastfeed her baby. As proven, nutritional support was essential to her
recovery particularly for the healing of her liver and also for her lactation. Finally, she was able to
breastfeed her baby because the nurses tried their best to maintain milk production by doing regular
pumping of her breasts.

 Domain: Organizational and Work-role Competencies

• A group of ICU nurses formed the team who cared for Mrs. Agua. During the time that they were
alternately caring for her, the nurses participated in critical care training and consultations to enhance
their knowledge and skills for caring high-risk postpartum women. This is an attempt to build and maintain
a therapeutic team to provide optimum therapy. Their critical care experience and concurrent OB nursing
training and consultations made them uniquely capable of individualizing Mrs. Agua's care.
•By expanding into a new care of nursing practice, the nurses opened a new knowledge in high-risk
OB nursing. For example, in their training in high-risk OB nursing, they became aware that not hearing the
sounds of her baby and not feeling the body of her baby could make Mrs. Agua think that her baby is not
alive. An interesting aspect of this situation was that, as ICU nurses, nutrition was not generally a
particularly salient issue for them. One nurse related:

"It's real common for us not to feed our patients because they are on very critical conditions that we are
more concerned with other aspects of care and with machines. The idea of feeding her with consideration
to supporting lactation came to our awareness through the training we had on caring for high-risk
postpartum women."

 Domain: Monitoring and Ensuring the Quality of Healthcare Practices

•The group of ICU nurses had ready access to the OB nurses with whom they had recently worked
during their training, thereby providing a readily accessible backup system for safe care. This combination
of ICU and OB care knowledge and skills enabled them to ensure that optimal supportive care was
provided. The nurses made adjustments in the care plan over and above that recommended by the
physicians. Examples included bringing the baby in to the mother, providing sound stimulation to the
mother, providing nutritional support.
•After many days of caring for Mrs. Agua, the nurses noticed that she was starting to improve in her
neurologic responses - pupil reactions, and level of consciousness. Gradually, she became more and more
alert and finally she was extubated. Her baby was crying in the room when she regained consciousness.
Remarkably, Mrs. Agua's liver healed; she recovered with no residual brain damage, and she went home
with her baby and the baby's father.