FROM NOVICE TO EXPERT

(Nursing Expertise Model)

Patricia Benner
Nursing Expertise Model
• Patricia Benner was interested in the Dreyfus Model of skill acquisition and applied it to nursing
• “How do nurses learn to do nursing?”
Dreyfus Model
• It is situational
• Describes the five level of skill acquisition and development: novice, advanced beginner, competent,
proficient, and expert
• Proposes that as a person improves in skill level, there is a corresponding change in the performance
of a given skill.
These are:
1. Movement from reliance on abstract principles and rules to use of past concrete experience
2. Shift from reliance on analytical, rule-based thinking to intuition
3. Change 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
4. Passage from a detached observer, standing outside the situation, to one of a position of
involvement, fully engaged in the situation
5. Experience-based skill acquisition is safer and quicker when it is founded on a sound educational
base
6. Skill refers to nursing interventions and clinical judgment skills in actual clinical situations
7. As the nurse gains experience, clinical knowledge becomes a good mix of practical and theoretical
knowledge.
8. Competency – an interpretively defined area of skilled performance identified and described by its
intent, functions, and meanings
9. Maxims – a mysterious description of skilled performance
NOVICE STAGE
• Characterized by a person who lacks background experience of the situation he/she is involved in.
• Simple rules and objective attributes should be given
• Examples are nursing students and professional nurses who have been assigned to a new area
ADVANCED BEGINNER
• Has minimally acceptable performance within a given situation
• Has enough experience to grasp aspects of a situation but not within the context of the situation
• Guided by rules and are oriented by the completion of tasks
• Nurses in this stage usually view the clinical situations given to her as a test of her abilities than in
terms of patient needs and responses
• Highly responsible for managing patient care but will still need other experienced nurses
• Examples are newly registered professional nurses
COMPETENT
• Learning from actual practice situations and by following the actions of others
• Exhibits a sense of mastery, increased level of efficiency, consistency, predictability, and time
management
• Ready to recognize patterns and identify which elements of the situation need the most attention
and which can be ignored
• Formulated new rules and reasoning procedures for a plan
• Most important task is active teaching and learning
PROFICIENT
• Has a holistic view of a particular situation
• Nurse’s performance is guided by maxims by this stage
• Show an intuitive grasp of the situation based on background understanding
• 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:
1. Demonstrate a clinical grasp and resource-based practice
2. Possesses embodied know-how
3. See the big picture
4. See the unexpected
Application of the Theory
• Use of phenomenological approaches to nursing practice
• Phenomenological approaches have resulted to the development of clinical promotion ladders, new
graduate – orientation programs, and clinical knowledge development seminars
• 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
• Nurse manager should devise a plan that carefully takes into consideration the employee nurses
level of competency in the clinical area
• Emphasizes 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
Human Caring Model: Jean Watson
JEAN WATSON:HUMAN CARING MODEL
• Nursing involves the application of ART and HUMAN SCIENCE through TRANSPERSONAL
TRANSACTIONS in order to help the person achieve mind, body and soul harmony.
• Caritas = to cherish and give special loving attention
JEAN WATSON
• She was born in West Virginia
• Educated: BSN, University of Colorado, 1964, MS, University of Colorado, 1966, PhD, University of
Colorado, 1973
• Distinguished Professor of Nursing and Chair in Caring Science at the University of Colorado Health
Sciences Center.
• Undergraduate and graduate degrees in nursing and psychiatric-mental health nursing and PhD in
educational psychology and counseling.
7 Assumptions on the Science of Caring
1. Caring can be effectively demonstrated & practiced only interpersonally
2. Effective caring promotes health an individual or family growth
3. Caring responses accept a person not only as he or she is now but as what he or she may become
4. A caring environment is one that offers the development of potential while allowing the person to
choose the best action for himself at a given point in time.
5. Caring is more “healthogenic” than is curing. The practice of caring integrates biophysical knowledge
with knowledge of human behavior to generate or promote health & to provide care to those who
are ill.
6. A science of caring is therefore complementary to the science of curing
7. The practice of caring is central to nursing
Major Elements of Caring Theory
• 1. Carative Factors
• 2. Transpersonal Caring Relationship
• 3. Caring Occasion/ Moment
Carative Factors
• Guide for the core of nursing
• Carative term to contrast with curative
• It honors the human dimensions of nursing work and the inner life world and subjective experiences
of patients
10 CARATIVE FACTORS
1. Formation of a Humanistic-Altruistic system of values - refers to the satisfaction one gets thru
giving and extension of the sense of self
2. Instillation of Faith-Hope – When modern science has nothing further to offer the person, the nurse
can continue to use faith-hope to provide a sense of well-being through beliefs which are meaningful
to the individual.
• 3. Cultivation of sensitivity to one’s self & to others -Development of one’s own feeling is needed to
interact genuinely and sensitively with others.
• Striving to become sensitive, makes the nurse more authentic, which encourages self-growth and
self-actualization, in both the nurse and those with whom the nurse interacts
3. Development of a helping-trusting relationship
  Strongest tool is the mode of communication, which establishes rapport and caring.
 Characteristics needed to in the helping-trust relationship are:
- Congruence
- Empathy – putting oneself in another’s “shoes”, honesty, real, genuine
- Warmth – moderate voice, congruent facial expressions
5. Promotion and acceptance of the expression of positive & negative feelings – appreciate
differences in individual and emotional understanding of a situation
6. Systematic use of a creative problem-solving caring process – highlights the importance of nursing
process in the provision of holistic nursing care
7. Promotion of transpersonal teaching-learning - The caring nurse must focus on the learning process
as much as the teaching process.
8. Provision for a supportive, protective and corrective mental, physical, societal &spiritual
environment – highlights the importance of internal and external environments on the health and
illness of man.
9. Assistance with gratification of human needs - Each need is equally important for quality nursing
care and the promotion of optimal health. All the needs deserve to be attended to and valued.
10. Allowance for existential-phenomenological-spiritual forces – understanding phenomena of human
existence by providing thought-provoking experiences that lead to a better understanding of the self
and others
Transpersonal Caring Relationship
• It describes how the nurse goes beyond an objective assessment, showing concerns toward the
person’s subjective and deeper meaning regarding their own health care situation
Caring Occasion
• Moment when the nurse and another person come together in such a way that an occasion for
human caring is created
Application of Theory
• Her model of nursing reflects & embodies the TRUE ESSENCE or nursing profession to this very day.
• It viewed the pt. as the Mind-Body-Spirit entity that needs holistic nursing care.
• One major implication of the theory is in the realm of BEDSIDE NURSING, where nurses of today
have particularly begun to neglect.
• The essence of nursing is in the caring aspect & caring is taking the wholeness, the totality of the pt.
into consideration.
• It is every nurse’s duty & obligation to care for his patient not by merely looking into and caring for
his physical disease but try to care for the pt. for who he is.
Activities of Living Model
Nancy Roper, Winifred W. Logan, Alison J. Tierney
“Nursing is the practice of assisting patients live through life.”
A Model Based on a Model of Living
• This model incorporates a life span approach, wherein the characteristics of the person are
considered with respect to prior development, current level of development and likely future
development
• Independence/dependence continuum is used
• Incorporates 12 activities of living engaged in by individuals either sick or well presented in a model
Concepts and Definitions
• Individuality of Living – the way in which a person attends to his activities of living with respect to
his developmental age, dependence/independence continuum
• Activities of Living – describes the person in the process of living from the perspective of an
amalgam of activities
• Dependence-Independence Continuum – refers to the factors and activities of the person that may
range from full incapacittaion to having the ability to achieve activities of daily living
Twelve Activities of Living
• Maintaining a safe environment
• Communication
• Breathing
• Eating and drinking
• Elimination
• Washing and dressing
• Controlling temperature
• Mobilization
• Working and playing
• Expressing sexuality
• Sleeping
• Death and dying
 • The model stresses continual patient assessment, facilitation of the patient’s normal activities of
living and individualized care
• Assessment of the patient is made within each activity of living account the independence/
dependence continuum
Application
• Highlights the importance of developmental assessment and of individualizing patient care
• Nurses should render care that reflects their understanding of pt’s developmental age and level,
degree of dependence/ independence, & how biological, psychological, sociocultural, environmental,
and politicoeconomic factors that can affect pt reaction
INTERPERSONAL ASPECTS OF NURSING THEORY
Joyce Travelbee
• “Nursing is assisting an individual, family or community to prevent or to cope with the experience of
illness and suffering, and, if necessary, to find meaning in these experiences.
• It emphasized on the therapeutic human relationship between the nurse and the patient.
Concepts and Definitions
• ORIGINAL ENCOUNTER – the initial interaction between the nurse and the patient
• EMERGING IDENTITIES – occur with the continuing nurse-patient relationship as both identifies with
one another with respect to the patient’s condition and the nurse’s ability to offer assistance.
• EMPATHY – nurse’s most valuable method of communicating with
patients
• Gain an intellectual understanding of the mental world and
psychological state of another
• SYMPATHY – process where an individual is able to comprehend the distress of another, be moved
or touched by another’s distress, and desires to alleviate the cause
• RAPPORT – when the nurse and patient have progressed through the four interlocking phases
preceding rapport and establishment of a nurse-patient relationship

APPLICATION OF THE THEORY

• The stages of interpersonal relations is important to be fully understood by nurses for the welfare of
their patients.
• It is also relevant today because this makes the patient feel human.
• This can later on help him find meaning to his experience.
MATERNAL ROLE ATTAINMENT THEORY
Ramona T. Mercer
• MATERNAL ROLE ATTAINMENT – interactional and developmental process occurring over time in
which the mother becomes attached to her infant, acquires competence in caretaking tasks involved
in the role, and expresses pleasure and gratification in the role.
STAGES OF MATERNAL ROLE ACQUISITION
 1. Anticipatory Stage– characterized by social and psychological adaptation to the maternal role ,
“What to expect when you are expecting”
2. Formal Stage - marked by the assumption of the maternal role at birth, social system; “My mother
always told me”
3. Informal Stage– new mother develops her own ways of mothering which are not conveyed by her
social system
4. Personal Stage – marked by the joy of motherhood; “I’m ready to have another one..”
MOTHER FACTORS
1. Empathy
2. Self-esteem and self-concept
3. Parenting received as child
4. Maturity and/or flexibility
5. Attitudes towards pregnancy, delivery and mothering
6. Pregnancy and/or birth experience
7. Health, depression, or anxiety, and
8. Role conflict or strain
INFANT/CHILD FACTORS
1. Temperament
2. Ability to give cues
3. Appearance
4. Characteristics
5. Responsiveness
6. Health
7. Father or mother’s intimate partner also contributes to the role attainment
8. Temperament
9. Ability to give cues
10. Appearance
11. Characteristics
12. Responsiveness
13. Health
14. Father or mother’s intimate partner also contributes to the role attainment
MATERNAL ROLE/ IDENTITY/ OUTCOME
a. Competence and/or confidence in the maternal role
b. Gratification and/or satisfaction derived form the role
c. Increased attachment to her infant
CHILD OUTCOMES
a. Cognitive and mental development
b. Attachment behaviors
c. Health
d. Social Competence
Concepts and Definitions
• Role Strain/Conflict – difficulty experienced by the mother in the light of fulfilling her maternal role
obligations
• Gratification-satisfaction – result of the mother’s interaction with her infant, marked by joy,
happiness, and/or pleasure
SOCIAL SUPPORT
• Amount of help the mother actually received, the satisfaction with the help, and the persons who
provided the help
FOUR AREAS OF SOCIAL SUPPORT
1. Emotional Support – the mother feels love, care, trust, and understanding
2. Informational Support – the mother is given useful information that will help her deal with a
problem or situation
3. Physical Support – mother is given direct help
4. Appraisal Support – mother is given ample feedback on how she is performing her maternal role in
order to evaluate the mother to evaluate herself in relation to how others have performed the
maternal role
Application of the Theory
• The most relevant application is in the field of maternal child health nursing.
• It is important for us, nurses, to assess the different factors that can affect a mother’s successful
acceptance and integration of the mothering role into her wholeness.
PEACEFUL END OF LIFE THEORY
Cornelia M. Ruland and Shirley M. Moore
• The occurrences and feelings of patients in near-death or end-of-life situations are personal and
highly individualized.
• Through assessment and interpretation of assessment findings that reflect the patient’s end-of-life
experience
• Nurse intervenes appropriately to attain a peaceful experience even when the patient cannot
communicate verbally
• The goal of care is to maximize the treatment; enhanced quality of life; peaceful death
CONCEPTS AND DEFINITIONS
• Not Being in Pain – being free of the suffering or symptoms of distress
• Experience of comfort – relief from discomfort and is the state of ease and peaceful contentment
• Experience of dignity and respect – idea of personal worth as expressed by autonomy and respect
for persons.
• Being at peace – feeling of calmness, harmony and contentment, and freedom from anxiety,
restlessness, worries, and fears.
• Closeness to significant others – feeling of connectedness to other human beings who care
APPLICATION OF THE THEORY
• This describes the crucial role nurses play in near-death or end-of-life situations
• 1. to the patient in end-of-life situations
• 2. to the patient’s significant others
Dorothea Orem's
Self-Care Theory
Dorothea Elizabeth
Orem (1914-2007)
History & Background
• One of foremost nursing theorists.
• Born 1914 in Baltimore, Maryland.
• 1939 – BSN, Catholic University of America
• 1945 – MSN, Catholic University of America
• During her professional career, she worked as a staff nurse, private duty nurse, nurse educator and
administrator and nurse consultant
• Received honorary Doctor of Science degree in 1976
• Published first formal articulation of her ideas in Nursing: Concepts of Practice in 1971, second in
1980, and in 1995.
• Orem died on June 22, 2007 at 92.
Orem’s general theory of nursing in three related parts:
• Theory of self care
• Theory of self care deficit
• Theory of nursing system
A. Theory of Self Care
• Self care – practice of activities that individual initiates and perform on their own behalf in
maintaining life ,health and well being
• Self care agency – is a human ability which is "the ability for engaging in self care" -conditioned by
age developmental state, life experience sociocultural orientation health and available resources
• Therapeutic self care demand – "totality of self care actions to be performed for some duration in
order to meet self care requisites
• Self care requisites-action directed towards provision of self care
3 Categories of Self Care Requisites
• Universal
• Developmental
• Health deviation
A. UNIVERSAL SELF CARE REQUISITES
• Common to all , ADL (needs that all people have)
• Identifies these requisites as:
a) Maintenance of sufficient intake of air ,water, food
b) Provision of care assoc with elimination process
c) Balance between activity and rest, between solitude and social interaction
d) Prevention of hazards to human life well being and
e) Promotion of human functioning
B. DEVELOPMENTAL SELF CARE REQUISITES
• Needs associated with developmental processes/ derived from a condition…. Or associated with an
event
– E.g. adjusting to a new job
– adjusting to body changes
C. HEALTH DEVIATION SELF CARE REQUISITES
• Required in conditions of illness, injury, or disease .these include:
– Seeking and securing appropriate medical assistance
– Being aware of and attending to the effects and results of pathologic conditions
– Effectively carrying out medically prescribed measures
– Learning to live with effects of pathologic conditions

B. THEORY OF SELF CARE DEFICIT

• Specific when nursing is needed because the person cannot carry out self-care activities
• Nursing is required when an adult (or in the case of a dependent, the parent) is incapable or limited
in the provision of continuous effective self care
Orem identifies 5 methods of helping:
1. Acting for and doing for others
2. Guiding others
3. Supporting another
4. Providing an environment promoting personal development in relation to meet future
demands
5. Teaching another
C. Theory of Nursing Systems
• Describes how the patient’s self care needs will be met by the nurse , the patient, or both
• Identifies 3 classifications of nursing system to meet the self care requisites of the patient:-
a) Wholly compensatory system
b) Partly compensatory system
c) Supportive – educative system
A. Wholly Compensatory System
• Patient is DEPENDENT
• Nurses accomplish ALL the patient’s therapeutic self-care
• Nurses compensate for the patient’s inability to engage in self-care
Example: Wholly Compensatory
• The patient is unconscious because he had stroke (CVA). The nurse provides total care for the patient
– feeding, hygiene, turning, elimination, suctioning of secretions to maintain effective respiration,
promoting safety, providing exercises of joints and body parts.
B. Partially Compensatory
• Patient can meet SOME needs
• Patient NEEDS NURSING assistance
• Both the nurse and the patient engage in meeting self-care needs.
Example: Partially Compensatory
• The patient had undergone appendectomy a day ago. He has a slight fever (37.9C), still in pain &
needs analgesic to relieve pain. He is advised to remain in bed but may be out of bed this afternoon.
He is still on NPO. The patient can do self-care activities like changing position in bed, but needs
nursing care for relief of pain & fever, assistance for ambulation & hygienic measures.
C. Supportive-Educative System
• Patient CAN MEET self-care requisites, but needs assistance with decision making or knowledge and
skills to learn self-care
Example: Supportive-Educative
• The patient had been newly diagnosed to have diabetes mellitus. The patient is capable of self-care
but she needs self-care knowledge on how to live well with diabetes-nutrition, activity/exercise, self-
monitoring of blood glucose, foot care, prevention of complications, medications.
Application of Orem’s Theory
• It emphasizes the need to understand the importance of self-care in promotion of health
• Focus on the patient’s capacity to perform self-care activities
• It also becomes clear that nurses today should not move away education and supportive measures –
HEALTH TEACHINGS.
Four Conservation Principles
Myra Estrine Levine
1920-1996
History and Background
• Born in Chicago
• Very fond of her father who was often ill and frequently hospitalized with GI problem. This was the
reason of choosing nursing as a career
• Also called as renaissance women-highly principled, remarkable and committed to patient’s quality
of care
• Died in 1996
Educational Achievement
• Diploma in nursing:-Cook county SON, Chicago, 1944
• BSN:-University of Chicago,1949
• MSN:-Wayne state University, Detroit, 1962
• Publication:-An Introduction to Clinical Nursing, 1969,1973 & 1989
Conservation Model
• To promote adaptation and maintain wholeness using the principles of conservation
• 3 Major Concepts
– A. Conservation
– B. Adaptation
– C. Wholeness
A. Adaptation
• Every individual has a unique range of adaptive responses
• Achieved through frugal, economic, contained, and controlled use of environmental resources by the
individual in his/her best interest
• Characteristics
• A. Historicity – based on personal and genetic past history
• B. Specificity - human being has unique stimulus-response pathways
• C. Redundancy – if one system is unable to ensure adaptation, then another may be able to
take over and complete the job.
B. Wholeness
• Exist when the interaction or constant adaptations to the environment permits the assurance of
integrity
• Promoted by use of conservation principle
Conservation
• The product of adaptation
• "Keeping together "of the life systems or the wholeness of the individual
• Maintain a proper balance between active nursing interventions coupled with patient participation
4 Conservation Principles
1. Conservation of energy
2. Conservation of structural integrity
3. Conservation of personal integrity
4. Conservation of social integrity
1. CONSERVATION OF ENERGY
• Refers to balancing energy input and output to avoid excessive fatigue
• includes adequate rest, nutrition and exercise
Example:
• Availability of adequate rest
Maintenance of adequate nutrition
• Regular pattern of exercise
2. CONSERVATION OF STRUCTURAL INTEGRITY
• Refers to maintaining or restoring the structure of body preventing physical breakdown And
promoting healing
Example:
• Assist patient in ROM exercise
Maintenance of patient’s personal hygiene
• Turn the unconscious pt at regular intervals to prevent pressure sores
3. CONSERVATION OF PERSONAL INTEGRITY
• Recognizes the individual as one who strives for recognition, respect, self awareness, selfhood and
self determination
Example:
• Recognize and protect patient’s space needs
• Assisting the pt to maintain good body image after chemotherapy
4. CONSERVATION OF SOCIAL INTEGRITY
• An individual is recognized as some one who resides with in a family, a community ,a religious group,
an ethnic group, a political system and a nation
Example:
• Position patient in bed to foster social interaction with other patients
• Avoid sensory deprivation
• Allowing visits from family memebers
Levels of External Environment
1. Pre-conceptual: Aspect of the world that individual are able to intercept
2. Operational: Elements that may physically affect individuals but not perceived by them: radiation,
micro-organism and pollution
3. Conceptual: Part of person's environment including cultural patterns characterized by spiritual
existence, ideas, values, beliefs and tradition
ORGANISMIC RESPONSE
• A change in behavior of an individual during an attempt to adapt to the environment
• Help individual to protect and maintain their integrity
FOUR TYPES OF ORGANISMIC RESPONSE
• 1. Flight or fight: An instantaneous response to real or imagined threat, most primitive response
• 2. Inflammatory: response intended to provide for structural integrity and the promotion of healing
• 3. Stress: Response developed over time and influenced by each stressful experience encountered by
person
• 4. Perceptual: Involves gathering information from the environment and converting it in to a
meaningful experience