By Joseph Gaccione (UNLV School of Nursing Associate Director of Communications)
To say Dr. Patricia Benner is known in the nursing world may be an understatement. After all, how many nurses can say they were honored as literal Living Legends by the American Academy of Nursing?
Dr. Benner is a nursing theorist, educator, and author of at least a dozen books, most notably From Novice to Expert: Excellence and Power in Clinical Nursing Practice. A professor emerita at the University of California School of Nursing, she is now a new member of UNLV School of Nursing as Dean’s Scholar. With a renowned reputation in the field, Dr. Benner joins UNLV Nursing to help shape nursing students’ education through a primary focus on accurately articulating knowledge and the value of practice as nurses advance towards a level of expertise.
How did you hear about UNLV?
Recently, I moved to Las Vegas, and I knew about the graduate programs in nursing education at UNLV School of Nursing. I had connections with UCLA and UC Irvine, and I wanted to continue to have some intellectual stimulation and connection with academia. I knew Dr. Amar from friends in Boston, and I reached out to her. We had met at conferences, so we had a great connection and overlapping interests, particularly in diversity and inclusion. She already knew my work, so that made it very easy.
Describe your role as Dean’s Scholar for UNLV Nursing.
Ordinarily in most universities, [this position] is a visiting scholar and that wasn't possible at UNLV because that means sort of an itinerant scholar. The vision both [me and Dr. Amar] had was a visiting scholar who would work with faculty and students and contribute in dialogue. I asked to fit in whatever way I could. [Also], I am [teaching in] classes; I have three lined up, and I'm meeting with faculty and students.
What inspired you to become a nurse?
I was interested in sciences. I originally thought I would go into medical missionary work, but found there was limited demand for science in medical missions. I considered medicine, but nursing was in high demand, so that's what I signed up for. It was a good choice for me. I love working with people, and I love all of the learning that occurs. When you're 18, you become a nurse, people will say, ‘Because you're a nurse, you understand this.’ Well, they were wrong. I had not a clue of the extremities, the suffering, and the life issues they would introduce to me, but I was amazed at the amount of trust and discussion of the deep concerns of illness and the fears. Patients would often practice talking to physicians with me and other nurses, but they felt free to talk about their suffering and perhaps impending death with me as a nurse in order to avoid talking to their family so much because of the burden for the family. I learned early on and we became very interested in the kind of practice that allowed for these compassionate strangers called nurses. One of my goals throughout my practice is to honor that, but also to work very hard, both in my scholarship and my leadership, to create institutions that support the work of nursing, the caring practices of mercy, because while nursing is very high tech, we're a frontline defense of the patient, the last line of defense of the patient, but we also have the possibility of being that one who supports that intimate stranger.
What is the connection between articulation and clinical nursing?
Practices are nuance-layered. They're made up of practitioners who've learned over time how to be a nurse, physician, or whatever practice one is in. There's a lot of knowledge that develops directly from practice, which is a way of knowing in its own right. We theorize and import science, and I'm all for the very best theories and sciences, but there is a frontline embodied skilled know-how that comes from being a nurse or being a physician that has to do with perceptual acuity. For example, there's one big transition in skill acquisition when one moves from beyond competency to proficiency. Suddenly, you have the possibility of dwelling and walking around in, and remembering whole concrete cases. It's this moving from the necessary period up through competency of depending on textbook list of signs and symptoms and matching that with the reality, to recognizing signs and symptoms from past whole concrete patient examples.
I’m always trying to call attention to articulating knowledge embedded in practice to make visible to the practitioners what they have learned over time, experientially, that allows them to recognize early warnings. When I first began talking about this 35 years ago, other nurses [would] say, ‘Nurses don't make diagnoses.’ Well, if nurses don't recognize these early warnings, then you have a problem of failure to rescue because the warning comes too late. I've always been trying to call attention to what is learned directly from practice and all the ways that practice is a way of knowing in its own right. It's important to theorize and get clearer understanding of what's going on in practice. Theory is dependent on practice to generate knowledge but we often act as if we stamp knowledge onto an inert passive practice, rather than we go to practice and we learn from it and we notice things from it.
How would you emphasize articulation and practice versus just theory?
I'm working hard on that. It's the ability to give vibrant language to situated thinking in action, and we tend to freeze frame action. We tend to describe all of our knowledge in terms of knowing that, knowing about, knowing why. And we have almost no language for this situated thinking in the action of knowing how and when and perceptual awareness. I'm always trying to bring in perceptual acuity, and thinking-in-action in order to make our language richer and more realistic. I just discovered this terrific emergency trauma triaging instrument, and the language is so situated and contextual.
Even in our current new AACN Essentials documents, the language is frozen in time. There is no account for transitions in patients across time, which are essential for good clinical reasoning in practice. That's why I think first-person experience narratives are a wonderful way to hear and see what relationships open up, what perceptual possibilities a person has when empathy and good patient connection are present. I am interested in what new disclosive spaces with patients are created by situated thinking in action and these relational qualities.
What drew you to nurse education?
I was always stunned at how much there was to learn and what the issues were. I became interested in education to try to improve our ability to teach what our experts in nursing practice learn over time and to make that kind of practice visible. I feel many of the accounts of nursing, the verbal descriptive accounts fit the beginner or the competent level, but not the expert. I think a lot of our accounts of the knowledge embedded in practice and the skilled know-how of expert practitioners is trivialized by the kind of formal language that doesn't account for situated thinking in action, and I think that's a problem in most fields.
What ways do you see COVID-19 changing nursing education and practice?
I think COVID proved we were such a protocol evidence-based guideline driven enterprise. Those are major intellectual resources, but with a novel disease with virtually no research, we didn't have any structures or processes to collect, validate, extend, research things that we had to learn in the frontlines. I mean, the analogs to other viruses didn't work. COVID was more neurological, but we were silenced because we did not have a practice of listening to what was being learned in the front lines.
The one resource I called attention to in my thinking and writing on the COVID experiences that we can go to the high reliability organization literature, where they literally study their frontline workers as the knowledge developers. In fighting wildfires, they always interview and unpack what the firefighters did that was either extremely successful or failed. Unfortunately, healthcare organizations were late coming to recognize the value of high reliability organizations actively trying to learn directly from frontline practice. I think COVID draws attention to this need for taking seriously what our expert practitioners are encountering and learning, especially in a whole new disease. COVID put an incredible strain on frontline nurses. Nurses and physicians went from seeing death maybe once a day or week to multiple deaths in one day. To be immersed in tragedy and to comfort both patients and families when they're separated and isolated has been a tremendous challenge.
Do you think going forward, this experience will make nurses stronger or it will make the job tougher?
I think a lot depends on our health care systems and leadership’s ability to wake up and realize how the efficiency and lack of attunement to the demands of the work make our healthcare organizations unfit for astute caring practices, early warnings, the ability to rescue patients. I think it is the onus isn't just on nursing, but on healthcare institutions to make their environments more fit for the practice demands of nursing, because it's hard to be an expert practitioner if you're just pressed for time and efficiency, and there's little space or respect given to how vital the practice of nursing is in order to rescue patients.
What would you hope is the biggest takeaway incoming nurses see from your work?
I think the importance of learning directly from practice and the vision for clinical reasoning, which is at the heart of nursing practice, that reasoning across time through changes in the patient or in the clinician’s understanding of what's going on with a patient. That intellectual and practical situated thinking action is so very different than the kind of nursing process, linear snapshot reasoning that [can be taught] in nursing school. If I could change one thing, it's the way we teach clinical reasoning, using nursing process only for the very first semester of school. After that, we would focus on teaching students to understand the nature of the whole clinical situation and to reason across time about the ongoing changes in the patient’s clinical condition.
- Dr. Patricia Benner - Nursing Theory (nursing-theory.org)
- Patricia Benner Novice to Expert Nursing Theory Explained - HRF (healthresearchfunding.org)
- Patricia Benner - Nursing Theorist (whyiwanttobeanurse.org)
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