MODULE 3

PATRICIA BENNER’S STAGES OF NURSING EXPERTISE

MARILYN ANNE RAY’S BUREAUCRATIC CARING

LEARNING TARGETS
Upon completion of this lesson, the nursing student can:

1. Highlight the major contributions of Benner and Ray as nursing theorists;

2. Describe the Dreyfus model and differentiate levels of expertise;
3. Apply the theory in nursing settings;
4. Highlight the theorists’ major contributions;
5. Describe the theoretical sources of bureaucratic caring; and,
6. Apply the theory in some nursing settings.
LESSON REVIEW/PREVIEW
1. True or False: Florence Nightingale came from a wealthy family and
her name was derived from her birthplace.

2. True or False: Her parents wanted her to be a nurse.

3. True or False: After publishing her books, she got married by the
age of 30.

4. According to Jean Watson, the essence of Nursing is “caring”. How

do you define caring in your viewpoint?
PATRICIA BENNER: CARING, CLINICAL
WISDOM AND ETHICS IN NURSING PRACTICE
• born in Hampton, Virginia

• baccalaureate of arts degree from

Pasadena College in 1964

• Master’s degree in Nursing with major

emphasis in medical-surgical nursing from
University of California, San Francisco,
School of Nursing

• has a wide range of clinical experience

“Nursing is a caring relationship and practice
that cares for and studies the lived
experiences of patients on health, illness, and
disease, and the relationships among these
three elements.”
- Patricia Benner
 "The Nurse - Patient Relationship is not a
uniform, professionalized blueprint but rather
a Kaleidoscope of intimacy and distance in
some of the most dramatic, poignant, and
mundane moments of life".
DREYFUS MODEL
•Novice (0 to 1 year)
•Advanced Beginner (1 to 2 years)
•Competent (2 to 3 years)
•Proficient (3 to 5 years) – intuitive
•Expert (>5 years) – clinical eye
DREYFUS MODEL
• proposes that as a person improves in skill level, there is a corresponding
change in the performance of a given skill:

üMovement from reliance on abstract principles and rules to use of past,

concrete experience.

üShift from reliance on analytical, rule-based thinking to intuition,

üChange in the learner’s perception of the situation from viewing it as a

compilation of equally relevant pieces to viewing it as an increasingly
complex whole in which some parts stand out as more or less relevant.
SKILL EXPERTISE

v refers to nursing v is developed when

interventions and the clinician tests and
clinical judgment modifies principle-
skills in actual
clinical situations. based expectations in
the actual setting.
NOVICE STAGE
• a person who lacks background experience of the situation he or she
is involved in

• simple rules and objectives, attributes should be given

• examples are nursing students and professional nurses who have

been assigned to an area totally different from the one they are
accustomed to
ADVANCED BEGINNER
• has enough experience to grasp aspects of a situation but not within
the context of the situation

• should be guided by rules and are oriented by the completion of tasks

• feels highly responsible for managing patient care but will still need
the help of other nurses who are more experienced than her

• examples are newly registered professional nurses

COMPETENT NURSE
• considerable conscious and deliberate planning which determines the
important aspects of present and future situations

• exhibits a sense of mastery, increased level of efficiency, consistency,

predictability, and time management
PROFICIENT NURSE
• already has a holistic view of a particular situation

• the nurse’s performance is guided by maxims by this stage

• can already show an intuitive grasp of the situation based on

background understanding

• can see changing relevance in a given situation including recognition

and implementation of skilled responses to the situation as it evolves
EXPERT NURSE
• does not rely anymore on the analytical principles of rules, guidelines,
and maxims to connect her understanding of the situation to an
appropriate action

• characterized by the following vital traits:

• demonstrate a clinical grasp and resource-based practice
• possess embodied know-how
• see the big picture
• see the unexpected
Competency – defined as an interpretively defined area of skilled
performance identified and described by its intent, functions, and
meanings.

Experience – the active process of refining and changing preconceived

theories, notions, and ideas when confronted with actual situations; it
reflects that there is communication between what is found in
practice and what is expected.
Maxim – a mysterious description of skilled performance.
✔ It requires a certain level of experience to recognize the implications of the
instructions.
✔ Paradigm case is a clinical experience that stands out.
✔ It alters the way the nurse will perceive and understand and open new
clinical viewpoints and alternatives.

Hermeneutics – interpretive; it describes meaningful human activities or phenomena in

a careful and detailed manner.
✔ The description is free from analytical assumptions. It is based purely on
practical understanding of thephenomena.
THEORY IN VIEW OF METAPARADIGMS
NURSING
• Described as a caring relationship and practice that cares for and
studies the lived experiences of

• patients on health, illness, and disease, and the relationships among

these three elements.
THEORY IN VIEW OF METAPARADIGMS
PERSON
• It is viewed as a self-interpreting being. The person does not come
into the world predefined. He gets defined in the course of living a
life. He has an effortless and non-reflective understanding of the self
in the world. He is a participant in common meanings and he is
embodied.
THEORY IN VIEW OF METAPARADIGMS
Embodiment refers to the body’s capacity to respond to meaningful
situations with 5 dimensions:

1. The unborn complex – the fetus and newborn baby does not yet
have any signs of the effects of culture

2. The habitual skilled body – refers to the body language of a person

as he learned through time by the processes of identification, imitation,
and trial and error
THEORY IN VIEW OF METAPARADIGMS
Embodiment refers to the body’s capacity to respond to meaningful
situations with 5 dimensions:

3. The projective body – refers to the predetermined action of the body in

response to a situation; for example, walking or running

4. The actual projected body – refers to the body’s capacity to fit or be skilled in a
given situation; for example, driving an automobile

5. The phenomenal body – refers to the body’s awareness of itself and its ability to
imagine and describe touch sensations
THEORY IN VIEW OF METAPARADIGMS
HEALTH

• This is defined as what can be assessed. Well-being is the human experience of

health or wholeness.

• Wellbeing and being ill are understood as distinct ways of being in the world.
Health is not merely the absence of disease or illness. A person may also have a
disease but not an illness.

• Illness is the human lived experience of loss of function or dysfunction.

• A disease is a state that can be assessed physically.

THEORY IN VIEW OF METAPARADIGMS
ENVIRONMENT

• Benner talked about situations instead of environment.

Situation is described as the social environment with a social
definition and meaningfulness. Each person’s past, present,
and future, including their own personal meanings, habits,
and perspectives, influence the present situation.
APPLICATION OF THE THEORY
• Benner’s contribution to the nursing profession is the use of
phenomenal approaches to nursing practice.

• Phenomenal approaches have resulted in the development of

clinical promotion ladders, new graduate orientation programs,
and clinical knowledge development seminars.
APPLICATION OF THE THEORY
• Her model is instrumental in differentiating knowledge
development and career progression in nursing. This allowed
nursing educators to realize that learning needs at the early
stages of clinical knowledge development are different from
those required at later or higher stages.
APPLICATION OF THE THEORY
• It is important to understand that different employees will have
different levels of skills.

• It is important to emphasize the importance of learning the skill

of involvement and caring through practical experience,
articulation of knowledge with practice, and the use of
narratives in undergraduate education.
APPLICATION OF THE THEORY
• It is important for nursing students and professional nurses alike
to learn through experience or by experiential learning.

• Learning by experience will allow you to gain mastery of a given

skill.
MARILYN ANN RAY
• 1958 – went to LA, CA work at OB-Gyn, ER, CCU

• 1960 – US Citizen, US Air Force- flight nurse, clinician, administrator,

educator, researcher with a rank of Colonel. The first nurse to go to
the Soviet Union with the Aerospace Medical association

• 1965 – BSN-MSN in MCN at the University of Colorado; Dr.

Madeleine Leininger, a nurse anthropologist, influenced Ray's life.

• 1973 – went back to Canada to be with her family, faculty in

McMaster University

• 1989 – appointed as an Eminent Scholar at Florida Atlantic

University and continues as Professor Emeritus

• Her research interests continue to focus on nurses, nurse

administrators and patients in critical care and intermediate care, and
in nursing administration in complex hospital organizational cultures
THEORETICAL SOURCES
• Dr. Leininger – transcultural nursing and ethnographic-ethnonursing
research methods.

• Hegel – posited the interrelationship among thesis, antithesis, and

synthesis.

• Chaos Theory – describes simultaneous order and disorder, and order

within disorder. Ray compares change in complex organizations with this
creative process and challenges nurses to step back and renew their
perceptions of everyday events, to discover the embedded meanings.
MAJOR CONCEPTS & DEFINITIONS
Holography – everything is a whole in one context and a part in
another, with each part being in the whole and the whole being in the
part

Caring – a complex transcultural, relational process grounded in an

ethical, spiritual context (charity and right action, love as compassion in
response to suffering and need and justice or fairness of what to be
done)
MAJOR CONCEPTS & DEFINITIONS
Spirituality – involves creativity and choice and is revealed in
attachment, love, and community

Spiritual- Ethical caring for nursing focuses on the facilitation of choices

for the good of others
MAJOR CONCEPTS & DEFINITIONS
Educational – formal and informal educational programs, use of
audiovisual media to convey information and other forms of teaching
and sharing information

Physical – related to the physical state of being, including biological and

mental patterns (mind and body)
MAJOR CONCEPTS & DEFINITIONS
Social-Cultural – ethnicity & family structures, intimacy with friends
and family, communication; social interaction and support.

Legal – meaning of caring include responsibility and accountability;

rules and principles to guide behaviors such as policies, procedures
informed consent; right to privacy

Technological – nonhuman resources, like machinery to maintain the

physiological well-being of the patient, diagnostic tests, knowledge and
skills needed to utilize these resources
MAJOR CONCEPTS & DEFINITIONS
Economic – includes money, budget, insurance systems, limitations and
guidelines imposed by managed care organizations, allocation of
human and material resources to maintain services

Political – power structure within health care administration, pattern of

decision making in the organization; role and gender stratification
among health care providers; competition for scarce human and
material resources
MAJOR ASSUMPTIONS
• The meaning of caring is highly differential, depending on its
structures (social-cultural, educational, political, economic, physical,
technological, legal).

• Caring is bureaucratic as well as spiritual/ ethical, given the extent to

which meaning can be understood in relation to the organizational
structure.

• Caring is the primordial construct and consciousness of nursing

THEORY IN VIEW OF METAPARADIGMS
NURSING holistic, relational, spiritual and ethical caring that seeks the good of self and
others in complex community, organizational and bureaucratic cultures

PERSON a spiritual and cultural being. are created by God, the Mystery of Being and
engage co-creatively to find meaning and value.

HEALTH provides a pattern of meaning for individuals, families, and communities. Beliefs
and caring practices about illness and health are central features of culture.

ENVIRONMENT a complex spiritual, ethical, ecological, and cultural phenomenon. It embodies

knowledge and conscience about the beauty of life forms and symbolic systems
or patterns of meaning. These patterns are transmitted historically and are
preserved or changed through caring values, attitudes, and communication.
APPLICATION TO NURSING
• Nursing Practice (Administration & Leadership)

• The theory of Bureaucratic Caring has direct application for nursing.

• This synthesis of behaviors and knowledge reflects the holistic nature of the
theory.

• This can transform the working environment, fostering ethical choices,

respect, and trust, resulting to successful organizations
APPLICATION TO NURSING
• Nursing Education: Useful in nursing education in terms of its broad
focus on caring in nursing and its conceptualization of the health care
system. Interconnectedness of all things

• Nursing Research: Particularly significant because it is grounded in the

philosophy of humanism and caring, and it encourages nurses to
utilize phenomenological-hermeneutics through the lens of caring
IMPLICATIONS OF THE THEORY
Clarity major structures are defined clearly, consistent with definitions commonly used by
practicing nurses

Simplicity the theory simplifies the dynamics of complex bureaucratic organizations

Generality the theory addresses the nature of nursing as caring, "What is the nature of caring in
nursing?”, "What is the nature of nursing practice as caring?". Philosophies are broad
and provide direction for the discipline.

Accessibility has undergone continued revisions based largely on research, empirical precision is high
with concepts grounded in observable reality

Importance issues that confront nurses today include economic constraints in the managed care
environment and the effects of these constraints (staffing ratio) on the nurse patient
relationship
REFERENCES
Alligood, M. (2018). Nursing theories and their work (9th ed.). Singapore: Elsevier.