INTRODUCTION TO NURSING THEORIES AND

THEORY APPLICATION:
DR.NISHA CLEMENT
ASSOCIATE
PROFESSOR,
ESIC COLLEGE OF
NURSING,
INDIRANAGAR,
BENGALURU.
 INTRODUCTION TO NURSING THEORIES AND
THEORY APPLICATION:
• A theory is a group of related concepts that propose action that guide practice.

• Theory refers to “a coherent group of general propositions used as principles

of
explanation”

• A nursing theory is a set of concepts, definitions, relationships, and assumptions or

propositions derived from nursing models or from other disciplines and project a
purposive, systematic view of phenomena by designing specific inter-relationships
among concepts for the purposes of describing, explaining, predicting, and /or
prescribing.
 • Kerlinger - theories as a set of interrelated concepts that give a systematic view of a
phenomenon (an observable fact or event) that is explanatory and predictive in nature.

• Theories are composed of concepts, definitions, models , propositions and are based
on
assumptions.

• They are derived through two principal methods:

• deductive reasoning
• inductive reasoning.
 ESSENTIAL
Concept ELEMENTS…..
• a mental idea of a phenomenon
• are the building blocks (the primary elements) of a theory.
• are basically vehicles of thought that involve images.
• are words that describe objects , properties, or events and are basic components of theory.
• Types of concepts:
• Empirical concepts

• Inferential concepts

• Abstract concepts.
 ESSENTIAL
Construct
ELEMENTS……………
• A phenomena that cannot be observed and must be inferred
• Are concepts developed or adopted for use in a particular theory. the key concepts of a given
theory are its constructs.
Proposition
• A statement of relationship between concepts
Process :
• Are series of actions, changes or functions intended to bring about a desired result .
• One takes systemic and continuous steps to meet a goal and uses both assessments and feedback
to direct actions to the goal.
• The delivery of nursing care within the nursing process is directed by the way specific
conceptual frameworks and theories define the person (patient), the environment, health and
VARIABL
ES

• Variables are the operational forms of constructs. they define the way
a construct is to be measured in a specific situation.

• Match variables to constructs when identifying what needs to

be assessed during evaluation of a theory-driven program
 CONCEPTUAL
MODEL
• Made up of concepts and propositions
• They represent ways of thinking about a problem or ways of representing
how complex things work the way that they do.
• Different frameworks will emphasize different variables and outcomes and
their interrelatedness.( Bordage, 2009)
• Models may draw on a number of theories to help understand a particular
problem in a certain setting or context. they are not always as specified as
theory.
 METAPARADIGMS IN NURSING- is a set of theories or ideas that provide
structure for how a discipline should function.
For a nursing discipline, these four basic concepts address the patient as a whole, the patient's
health and well-being, the patient's environment and the nursing responsibilities.
Person
• recipient of care, including physical, spiritual, psychological, and sociocultural components.
• individual, family, or community
Environment
• all internal and external conditions, circumstances, and influences affecting the person
Health
• degree of wellness or illness experienced by the person
Nursing
• actions, characteristics and attributes of person giving care
OBJECTIV
ES
• To Assess The Patient Condition By The Various Methods Explained By The Nursing
Theory
• To Identify The Needs Of The Patient
• To Demonstrate An Effective Communication And Interaction With The Patient.
• To Select A Theory For The Application According To The Need Of The Patient
• To Apply The Theory To Solve The Identified Problems Of The Patient
• To Evaluate The Extent To Which The Process Was Fruitful.
 PURPOSES OF NURSING
THEORIES
IN PRACTICE:
• Assist nurses to describe, explain, and predict everyday experiences.
• Serve to guide assessment, interventions, and evaluation of nursing care.
• Provide a rationale for collecting reliable and valid data about the health status of
clients, which are essential for effective decision making and implementation.
• Help to describe criteria to measure the quality of nursing care.
• Help build a common nursing terminology to use in communicating with other
health professionals.
• Ideas are developed and words are defined.
• Enhance autonomy (independence and self-governance) of nursing
through defining its own independent functions.
IN EDUCATION: PURPOSE
…..design
• Provide a general focus for curriculum
• Guide curricular decision making.
IN RESEARCH:
• Offer a framework for generating knowledge and new ideas.
• Assist in discovering knowledge gaps in the specific field of
• Offer
study. a systematic approach to identify questions for study; variables,
select findings, and validate nursing interventions.
interpret
• Approaches to developing nursing theory
• Borrowing conceptual frameworks from other
• Inductively
disciplines. looking at nursing practice to theories/concepts
explain
discoverphenomena. to
• Deductively looking for the compatibility of a wit
general practice.
nursing nursing theory h
• Frame questions from practicing nurse about using nursing
theory
 CHARACTERISTICS OF
THEORIES
• Interrelating concepts in such a way as to create a different way of looking at
a particular phenomenon.
• Logical in nature.
• Generalizable.
• Bases for hypotheses that can be tested.
• Increase the general body of knowledge within the discipline through the
research implemented to validate them.
• Used by the practitioners to guide and improve their practice.
• Consistent with other validated theories, laws, and principles but will leave
open unanswered questions that need to be investigated
 IMPORTANCE OF NURSING
THEORIES
• Aims to describe, predict and explain the phenomenon of nursing
• Provide the foundations of nursing practice
• Help to generate further knowledge
• Indicate in which direction nursing should develop in the future.
• It helps us to decide what we know and what we need to know
• Ithelps to distinguishwhat should form the basis of practice by
explicitly describing nursing.
• Better patient care
• Enhanced professional status for nurses
• Improved communication between nurses, and guidance
for research and education
 IMPORTANCE OF NURSING
THEORIES
• The main exponent of nursing – caring – cannot be measured, it is vital to
have the theory to analyze and explain what nurses do

• As medicine tries to make a move towards adopting a more multidisciplinary

approach to health care, nursing continues to strive to establish a unique
body of knowledge

• This can be seen as an attempt by the nursing profession to maintain its

professional Boundaries
 BASIC PROCESSES IN THE DEVELOPMENT OF NURSING
THEORIES
• Nursing theories are often based on and influenced by broadly applicable processes and
theories. following theories are basic to many nursing concepts.

A. General system theory:

• It describes how to break whole things into parts and then to learn how the parts work
together in " systems".
• These concepts may be applied to different kinds of systems, e.g.. molecules in chemistry ,
cultures in sociology, organs in anatomy and health in nursing.
 B. ADAPTATION
THEORY
• It defines adaptation as the adjustment of living matter to other living
things and to environmental conditions.
• Adaptation is a continuously occurring process that effects change and
involves interaction and response.
• Human adaptation occurs on three levels:
• --- the internal ( self )
• --- the social (others)
• --- and the physical ( biochemical reactions )
 C. DEVELOPMENTAL THEORY

• It outlines the process of growth and development of humans as orderly and

predictable, beginning with conception and ending with death.

• The progress and behaviors of an individual within each stage are unique.

• The growth and development of an individual are influenced by heredity ,

temperament, emotional, and physical environment, life experiences and
health status.
 EVOLUTION OF NURSING THEORIES &
APPLICATION
• History of professional nursing begins with Florence nightingale.
• Later in last century nursing began with a strong emphasis on practice.
• following that came the curriculum era which addressed the questions
about what the nursing students should study in order to achieve the
required standard of nursing.
• as more and more nurses began to pursue higher degrees in nursing, there
emerged the research era.
• nursing practice and lead to the continued development of the theories.
 EVOLUTION OF NURSING THEORIES &
APPLICATION…………….

• Later graduate education and masters education was given much

importance.
• Development of the theory era was a natural outgrowth of the research era.
• With an increased number of researches it became obvious that the research
without theory produced isolated information; however research and theory
produced the nursing sciences.
• Within the contemporary phase there is an emphasis on theory use and
theory based
 HISTORY………
….
• Nightingale (1860): To Facilitate "The Body’s Reparative Processes" By
Manipulating Client’s Environment
• Paplau 1952: Nursing Is; Therapeutic Interpersonal Process.
• Henderson 1955: The Needs Often Called Henderson’s 14 Basic Needs
• Abdellah 1960: This Theory Focus On Delivering Nursing Care For The
Whole Person To Meet The Physical, Emotional, Intellectual, Social, And
Spiritual Needs Of The Client And Family.
• Orlando 1962: To Ida Orlando (1960), The Client Is An Individual; With A
Need; That, When Met, Diminishes Distress, Increases Adequacy, Or
Enhances Well-being.
 HISTORY…………
…..
• Johnson's theory 1968: Dorothy Johnson's theory of nursing 1968 focuses
on how the client adapts to illness and how actual or potential stress can
affect the ability to adapt. the goal of nursing to reduce stress so that; the
client can move more easily through recovery.
• Rogers 1970: to maintain and promote health, prevent illness, and care for
and rehabilitate ill and disabled client through "humanistic science of
nursing"
• Orem1971: this is self-care deficit theory. nursing care becomes necessary
when client is unable to fulfill biological, psychological, developmental, or
social needs.
 HISTORY…
…
• King 1971: To Use Communication To Help Client Reestablish Positive
Adaptation To Environment.
• Neuman 1972: Stress Reduction Is Goal Of System Model Of Nursing
Practice.
• Roy 1979: This Adaptation Model Is Based On The Physiological,
Psychological, Sociological And Dependence-independence Adaptive
Modes.
• Watson’s Theory 1979: Watson’s Philosophy Of Caring 1979 Attempts To
Define The Outcome Of Nursing Activity In Regard To The; Humanistic
Aspects Of Life.
 CLASSIFICATION OF NURSING
THEORIES
Depending On The Generalizability Of Their Principles
• Meta Theory: The Theory Of Theory. Identifies Specific Phenomena
Through Abstract Concepts.
• Grand Theory: Provides A Conceptual Framework Under Which The
Key Concepts And Principles Of The Discipline Can Be Identified.
• Middle Range Theory: Is More Precise And Only Analyses A
Particular Situation With A Limited Number Of Variables.
• Practice Theory: Explores One Particular Situation Found In Nursing.
It Identifies Explicit Goals And Details How These Goals Will Be
Achieved.
 SCHOOL OF THOUGHTS IN NURSING THEORIES-
1950-1970
Interactio Outcom
Need theorists
n e
Theorists theorists
•King
•Orlando
•Peterson and •Johnson
•Abdellah
Zderad •Levine
•Henderson
•Paplau •Rogers
•Orem
•Travelbee •Roy
•Wiedenbach
 THEORIES CAN ALSO BE
CATEGORIZED AS:
• "NEEDS "THEORIES.
• "INTERACTION"
THEORIES.
• "OUTCOME
"THEORIES.
• "HUMANISTIC
THEORIES"
NEEDS"
THEORIES

• These theories are based around helping individuals to fulfill their

physical and mental needs.

• Needs theories have been criticized for relying too much on the
medical model of health and placing the patient in an overtly
dependent position.
 “INTERACTION"
THEORIES
• These theories revolve around the relationships nurses form with patients.
• These theories have been criticized for largely ignoring the medical model of
health and not attending to basic physical needs.

"OUTCOME" THEORIES
• These portray the nurse as the changing force, who enables individuals to adapt to or
cope with ill health (Roy 1980).
• Outcome theories have been criticized as too abstract and difficult to implement
in practice (Angleton and Chalmers 1988).
 "HUMANISTIC"
THEORIES:
• Developed in response to the psychoanalytic thought that a person’s destiny was
determined early in life.
• Emphasize a person’s capacity for self actualization .
• Humanists believes that the person contains within himself the potential for healthy
and creative growth.
• Carl Rogers developed a person –centered model of psychotherapy that emphasizes
the
uniqueness of the individual.
• The major contribution that rogers added to nursing practice is the understanding that each
client is a unique individual, so person-centered approach now practice in nursing.
 TYPES OF NURSING
1 Florence Nightingale’s Legacy of •Focuses on nursing and the patient environment
THEORIES
. caring relationship.
2 •Helping process meets needs through the art of
. individualizing care.
•Nurses should identify patients ‘need-for –help’ by:
Ernestine Wiedenbach: The • Observation
helping art of clinical nursing • Understanding client behavior
• Identifying cause of discomfort
• Determining if clients can resolve problems or have
a need for help
3 Virginia Henderson’s Definition of •Patients require help towards achieving independence.
. Nursing •Derived a definition of nursing
•Identified 14 basic human needs on which nursing care
is based.
4 Faye G. Abedellah’s Typology of •Patient’s problems determine nursing care
. twenty one Nursing problems
5. Lydia E. Hall :Care, Cure, Core •Nursing care is person directed towards self love.
 TYPES
S.I. Type of theory …
Key points

6 Jean Watson’s Philosophy •Caring is a universal, social phenomenon that is only

and Science of caring effective when practiced interpersonally considering
humanistic aspects and caring.

•Caring is central to the essence of nursing.

7 Patricia Benner’s Novice to •Described systematically five stages of skill acquisition in

Expert nursing practice – novice, advanced beginner,
competent, proficient and expert.
 TYPES OF CONCEPTUAL MODELS AND GRAND
1. THEORIES
Dorothea E. Orem’s Self •Self–care maintains wholeness.
care deficit theory in •Three Theories:
nursing • Theory of Self-Care
• Theory of Self-Care Deficit
• Theory of Nursing Systems
•Nursing Care:
• Wholly compensatory (doing for the patient)
• Partly compensatory (helping the patient do for himself or herself)
• Supportive- educative (Helping patient to learn self care and emphasizing
on the importance of
nurses’ role
2. Myra Estrin Levine’s: •Proposed that the nurses use the principles of conservation of:
The • Client Energy
conservation model • Personal integrity
• Structural integrity
• Social integrity
•A conceptual model with three nursing theories –
• Conservation
• Redundancy
• Therapeutic intention
 TYPES OF CONCEPTUAL MODELS AND GRAND
THEORIES….. Key points
S.I. Type of theory
No
3 Martha E.Roger’s: •Person and environment are energy fields
Science of unitary human •Nursing is a basic scientific discipline
beings •Nursing is using knowledge for human betterment.
•The unique focus of nursing is on the unitary or irreducible human being and the
environment (both are energy fields) rather than health and illness
4. Dorothy E.Johnson’s •Individuals maintain stability and balance through adjustments and adaptation to the
Behavioural system forces that impinges them.
model •Individual as a behavioural system is composed of seven subsystems: the
subsystems of attachment, or the affiliative, dependency, achievement, aggressive,
ingestive-eliminative and sexual.
•Disturbances in these causes nursing problems.
5. Sister Callista: •Stimuli disrupt an adaptive system
Roy‘s Adaptation model •The individual is a biopsychosocial adaptive system within an environment.
•The individual and the environment provide three classes of stimuli-the focal, residual
and contextual.
•Through two adaptive mechanisms, regulator and cognator, an individual
demonstrates adaptive responses or ineffective responses requiring nursing
interventions
 TYPES OF CONCEPTUAL MODELS AND GRAND
S.I.N Type of THEORIES…..
theory Key points
o
6. Betty Neuman’s : Health •Neuman’s model includes intrapersonal, interpersonal and extra personal stressors.
care systems model •Nursing is concerned with the whole person.
•Nursing actions (Primary, Secondary, and Tertiary levels of prevention) focuses on
the variables affecting the client’s response to stressors.

7. Imogene King’s Goal •Transactions provide a frame of reference toward goal setting.
attainment theory •Major concepts (interaction, perception, communication, transaction, role, stress,
growth and development)
•Perceptions, Judgments and actions of the patient and the nurse lead to reaction,
interaction, and transaction (process of nursing).
8. Nancy Roper, •Individuality in living.
WW.Logan and •A conceptual model of nursing from which theory of goal attainment is derived.
A.J.Tierney A model for •Living is an amalgam of activities of living (ALs).
nursing based on a •Most individuals experience significant life events which can affect ALs causing
model of living actual and potential problems.
•This affects dependence – independence continuum which is bi-directional.
•Nursing helps to maintain the individuality of person by preventing potential
problems, solving actual problems and helping to cope.
 TYPES OF CONCEPTUAL MODELS AND GRAND
S.I Type of theory Key points
THEORIES
9 Hildegard E. •Interpersonal process is maturing force for personality.
Peplau: •Stressed the importance of nurses’ ability to understand own behavior to help others identify perceived
Psychodynami difficulties.
c Nursing •The four phases of nurse-patient relationships are:
Theory • 1. Orientation
• 2. Identification
• 3. Exploitations
• 4. Resolution
•The six nursing roles are:
• 1. Stranger
• 2. Resource person
• 3. Teacher
• 4. Leader
• 5. Surrogate
• 6. Counselor
•Interpersonal process alleviates distress.

10 Ida Jean Orlando’s •Nurses must stay connected to patients and assure that patients get what they need, focused on patient’s
Nursing Process verbal and non verbal expressions of need and nurse’s reactions to patient’s behavior to alleviate distress.
Theory •Elements of nursing situation:
• Patient
• Nurse reactions
• Nursing actions
 TYPES……
S.I.N Type of theory Key points
o …..
11 Joyce Travelbee’s Human To •Therapeutic human relationships.
Human Relationship Model •Nursing is accomplished through human to human relationships that began
with the original encounter and then progressed through stages of emerging
identities.

12 Kathryn E. Barnard’s Parent •Growth and development of children and mother–infant relationships
Child Interaction Model •Individual characteristics of each member influence the parent–infant
system and adaptive behavior modifies those characteristics to meet the
needs of the system.

13 Ramona T.Mercer’s :Maternal •A complex theory to explain the factors impacting the development of
Role Attainment maternal role over time.
14 Katharine Kolcaba’s Theory of •Comfort is desirable holistic outcome of care.
comfort •Health care needs are needs (physical, psycho spiritual, social and
environmental needs) for comfort, arising from stressful health care
situations that cannot be met by recipients’ traditional support system.
•Comfort measures include those nursing interventions designed to
address
the specific comfort needs.
 TYPES:
S.I.No Type of theory Key points
……..
15 Madeleine Leininger’s •Caring is universal and varies transculturally.
Transcultural nursing, culture- •Major concepts include care, caring, culture, cultural values and cultural
care theory variations
•Caring serves to ameliorate or improve human conditions and life base.
•Care is the essence and the dominant, distinctive and unifying feature
of
nursing
16 Rosemarie Rizzo Parse’s •Indivisible beings and environment co-create health.
:Theory of human becoming •A theory of nursing derived from Roger’s conceptual model.
•Clients are open, mutual and in constant interaction with environment.
•The nurse assists the client in interaction with the environment and co
creating health

17. Nola J.Pender’s :The Health •Promoting optimum health supersedes disease prevention.
promotion; model •Identifies cognitive, perceptual factors in clients which are modified by
demographical and biological characteristics, interpersonal influences,
situational and behavioural factors that help predict in health promoting
behaviour
 DR PATRICIA BENNER
INTRODUCTION
THEORY
Dr. Patricia Benner introduced the concept that expert nurses develop skills and understanding
of patient care over time through a sound educational base as well as a multitude of
experiences.
she proposed that one could gain knowledge and skills ("knowing how") without ever learning
the theory ("knowing that").
she further explains that the development of knowledge in applied disciplines such as
medicine and nursing is composed of the extension of practical knowledge (know how)
through research and the characterization and understanding of the "know how" of clinical
experience.
she conceptualizes in her writing about nursing skills as experience is a prerequisite for
becoming an expert
 ABOUT THE
THEORIST
• PATRICIA E. BENNER, R.N., PH.D., PROFESSOR AT THE UNIVERSITY OF
CALIFORNIA, SAN FRANCISCO.
• BSC IN NURSING - PASADENA COLLEGE/POINT LOMA COLLEGE
• MS IN MED/SURG NURSING FROM UCSF
• PHD -1982 FROM UC BERKELEY
• 1970S - RESEARCH AT UCSF AND UC BERKELEY
• HAS TAUGHT AND DONE RESEARCH AT UCSF SINCE 1979
• PUBLISHED 9 BOOKS AND NUMEROUS ARTICLES
• PUBLISHED ‘NOVICE TO EXPERT THEORY’ IN 1982
• RECEIVED BOOK OF THE YEAR FROM AJN IN 1984,1990,1996, 2000
• HER WEB ADDRESS IS AT: HTTP://WWW.PATRICIABENNER.COM
• HER PROFILE CAN BE OBTAINED AT HTTP://NURSEWEB.UCSF.EDU/WWW/IX-FD.SHTML
BENNER : AS
AUTHOR
Dr. Benner is the author of books including:
1.From Novice to Expert
2. The Primacy of Caring
3.Interpretive Phenomenology:
Embodiment, Caring and Ethics in Health and
Illness
5. The Crisis of Care
4.Expertise in Nursing Practice:
Clinical Judgment, and Ethics Caring,
6. Caregiving
7. Clinical Wisdom and Interventions
in Critical Care: A Thinking-In-Action Approach.
Is an internationally noted researcher and lecturer
on health, stress and coping, skill acquisition and
ethics.

Recently elected an honorary fellow of the Royal

College of Nursing.

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.
AN INFLUENTIAL NURSE IN THE DEVELOPMENT OF THE
PROFESSION OF NURSING

Patricia Benner’s research

and theory provides
the profession
work of nursing
with what we now know as
the Novice to Expert
model, also known as
Benner’s Stages of
Clinical Competence.
Benner’s work as applied to
the nursing profession
is adapted from
the Dreyfus Model of
Skill Acquisition.
SKILL ACQUISITION

“The utility of the concept of skill

acquisition lies in helping the
teacher understand how to assist
the learner in advancing to the
next level” (McClure, 2005)
T D RE M ODE OF S KILL
HE YFUS L ACQUISITION
Dr. Benner categorized nursing into 5 levels of capabilities: novice, advanced
beginner, competent, proficient, and expert.

She believed experience in the clinical setting is key to nursing because it allows
a nurse to continuously expand their knowledge base and to provide holistic,
competent care to the patient.

Her research was aimed at discovering if there were distinguishable,

characteristic differences in the novice’s and expert’s descriptions of the same
clinical incident.
 LEVELS OF NURSING
EXPERIENCE
• SHE DESCRIBED 5 LEVELS OF NURSING
EXPERIENCE AS;
• NOVICE
• ADVANCED BEGINNER
• COMPETENT
• PROFICIENT
• EXPERT
 N OVICE
The person has no background experience of the
situation in which he or she is involved.
There is difficulty discerning between relevant and
irrelevant aspects of the situation.
Beginner with no experience
Taught general rules to help perform tasks
Rules are: context-free, independent of specific cases,
and applied universally
,
Rule-governed behavior is limited and inflexible
Ex. “Tell me what I need to do and I’ll do it.”
Generally this level applies to nursing
students.
ADVANCED BEGINNER
• Demonstrates acceptable performance

• Has gained prior experience in actual situations to recognize

recurring meaningful components

• Principles, based on experiences, begin to be formulated to

guide actions
• Nurses functioning at this level are guided rules and
by oriented by task completion.
• Still requires mentor or experienced nurse assist with
defining
to situations, to set priorities, and to integrate practical
knowledge
 COMPETENT
After two to three years in the same area of nursing the nurse moves into the
Competent Stage of skill acquisition.
Most pivotal in clinical learning because the learner must begin to recognize
patterns and determine which elements of the situation warrant attention and
which can be ignored.
Devises new rules and reasoning procedures for a plan
while applying learned rules for action on the basis of
the relevant facts of that situation.
More aware of long-term goals
Gains perspective from planning own actions based on
conscious, abstract, and analytical thinking and helps
to achieve greater efficiency and organization
 PROFICIENT
After three to five years in the same area of nursing the nurse moves into the Proficient Stage
“The nurse possesses a deep understanding of situations as they occur, less conscious planning is
necessary, critical thinking and decision-making skills have developed” (Frisch)

The performer perceives the information as a whole (total picture) rather than in terms of aspects and
performance.

Proficient level is a qualitative leap beyond the competent.

Nurses at this level demonstrate a new ability to see changing relevance in a situation including the
recognition and the implementation of:

• Skilled responses to the situation as is it evolves.

• Perceives and understands situations as whole parts
• More holistic understanding improves decision-making
• Learns from experiences what to expect in certain situations
and
how to modify plans
 EXPERT
This stage occurs after five years or greater in the same area of nursing (experienced nurses
changing areas of nursing practice may progress more quickly through the five stages)

The expert performer no longer relies on an analytic principle (rule, guideline, maxim) to connect
her or his understanding of the situation to an appropriate action.

The expert nurse, with an enormous background of experience, now has an

intuitive grasp of each situation and zeroes in on the accurate region of the
problem without wasteful consideration of a large range of unfruitful,
alternative diagnoses and solutions.

The expert operates from a deep understanding of the total situation.

NURSING THEOR
APPLICATION OF Y
BENNER’ S
Nursing applies Benner’s Theory through:
• Nursing school curriculum
• Building clinical ladders for nurses (Frisch)
• Developing mentorship programs
– Preceptors for student nurses
– Mentors for newly graduated nurses (Dracup and Bryan-
Brown, 2014)
•Development of the Clinical Simulation Protocol (Larew et al.,
2016)
FOUR DOMAINS OF NURSING PARADIGM

1. Client/Person
2. Health
3. Environment/Situation
4. Nursing
 C LIENT/ P ERSON

“The person is a self- interpreting being, that is the

person does not come into the world predefined but
gets defined in the course of living a life.”
- Dr. Benner
 HEA
LTH
Dr. Benner focuses on the lived experience
of being healthy and being ill.
Health is defined as what can be assessed,
whereas well being is the
human experience of health
or wholeness.
Well being and being ill are
understood as distinct ways
of being in the world.
ENVIRONMENT/SITUATION
Benner uses situation rather than environment
because situation conveys a social environment
with social definition .

“To be situated implies that

one has a past, present, and
future and that
all of these aspects…
influence the current situation.”
- Dr. Benner
 NURSING
Nursing is described as a caring relationship, an
“enabling condition of connection and concern.”
-Dr. Benner

“Caring is primary because caring sets up the possibility of giving

and receiving help.”

Nursing is viewed as a caring practice whose science is guided by

the moral art and ethics of care and responsibility.

Dr. Benner understands that nursing practice as the care and study
of the lived experience of health, illness, and disease and the
relationships among the three elements.
 M ODERN THEORISTS

Benner is a relatively modern theorist, with

her work having been done in the early
1980’s.
Since that time health care has seen
the
advent of DRG’s, managed care, an increase in
the acuity of patients in the hospital related to
back admissions. early dischargeand bounce
 HOSPITAL SURVIVAL
Her theory of expert nurses is critical today as the
profession begins to realize the aging of the members of its
workforce and the increasing age of the population who will
require more nursing services.

Her theory is applicable today, as it was at its publication,

and provides us with a foundation to use for
clinical competence, a tool to use to assess
assigning
competence in
the staff nurse.
 WHAT CAN NURSE LEADERS
Nurse leaders can help address DO?
thegraduate
and staff retention by supporting new issues ofnurses
nursingby:
shortage

• Advocating for transition or residency programs to

• competency, confidence & satisfaction of new RNs
• Maintaining a healthy working environment
Not using novice RNs to cover for staffing before the end of
shortage orientation period
Zero tolerance for lateral violence or bullying
•Supporting experienced RNs who are serving as preceptors and mentors for
novice RNs
 SHAPING OUR FUTURE NURSE LEADERS
• New graduate nurses are the future employee pool
Job satisfaction & retention are greatly influenced by the quality of
orientation and support received by the new graduate nurse.
A positive exper•ience will encourage the now proficient nurse to
mentor novice nurses & give them the same positive experience
he/she had during the transition period.

The m e d i o c re t e•a cher

tells. T h e good t
eacher explains.
The s u p e r i o r t e a c h e r
demonstrates.
The g rea t t e a c h e r
inspires.
 SIGNIFICANCE OF THE THEORY

• These levels reflect movement from reliance on past abstract principles

• to the use of past concrete experience as paradigms
• change in perception of situation as a complete whole in which
certain parts are relevant
• each step builds on the previous one as abstract principles are
refined and expanded by experience and the learner gains clinical
expertise.
 SIGNIFICANCE OF THE
THEORY
• This theory changed the profession's understanding of what it means to be an
expert
• placing this designation not on the nurse with the most highly paid or most
prestigious position, but on the nurse who provided "the most exquisite nursing
care.
• It is recognized that nursing was poorly served by the paradigm that called for
all of nursing theory to be developed by researchers and scholars, but rather
introduced the revolutionary notion that the practice itself could and should
inform theory.
 APPLICATION OF THEORY TO
PRACTICE
Aim- Course on -the challenges of central line associated blood stream infections-Kevin
Arnold, RN, BSC(N)

KLA Education Services LLC is accredited by

the State of California Board of Registered
Nursing.
Concepts:
• Considers ‘excellent care practices’ gained through an evolutionary process grown
from experiential learning and transmission into practical skills.
• She stresses the importance of retaining and rewarding clinicians for their expertise
• Her
(McEwen & Wills,
central 2011).are those of competence, skill, acquisition, experience,
concepts
clinical
knowledge, and practical knowledge (McEwen & Wills,
2011).
 CONCEPT IN
NURSING
Seven Domains Of Practice In Nursing:
• Helping role
• Teaching role
• Diagnostic client-monitoring function
• Effective management of rapidly changing situations
• Administering and monitoring therapeutic interventions and
regimens
• Monitoring and ensuring quality of health care practices
• Organizational and work-role competencies (McEwen & Wills,
2011)
 CONCEPTS
…
• These levels reflect progress from reliance on past abstract principles to the
use of past concrete experience as paradigms and change in perception of
situation as a complete whole in which certain parts are relevant (nursing
theories, 2013).
• This process evolves through the five levels of skill acquisition as clinicians
use clinical guidelines and algorithms or ‘rules’ at first and through
experience and empirical research, transition to the use of a more focused
intuition.
 Proposition
s:
• Clinicians have varying situational experience which is what separates novice from
expert.
• As clinicians test and refine propositions, hypotheses, and expectations,
expertise develops.
• Benner considers experience a requisite for becoming and expert and
distinguishes a
difference in a nurse that “knows that” and “knows how” (benner, 1984).
• As clinicians move to a higher level of practice, a more holistic approach is
used.
• the expert clinician perceives situations as a whole and moves past concrete situations
to focus directly on the problem.
• no time is wasted on irrelevant items.
• benner proposes nurses rely heavily on past experience and nurses must deepen
 Propositions…….Benners
• emphasizes knowledge development through experience & strengthened through reflection.
concept
• critical thinking is necessary at all skill levels.
• analytical thinking the backbone for problem solving (Benner, 1984).
• clinical judgment an essential skill also for all nurses.
• with expert nurses her theory proposes actions are determined quickly without referring
to
rules or guidelines.
• the process of reflection combined with the use of narratives as nurses often know more than
they can communicate (benner, 1984).
• the use of narratives helps to articulate meaning and further help develop learning
from decision making related to their respective outcomes.
• benner highlights the expert nurse as one that uses intuition based on unique
attributes obtained through experience, self-awareness, and reflection.
 LITERATURE
EXAMPLE
A search via cumulative index of nursing and allied health literature reveals many listings with articles
citing (2007) used Benner’s model
• in a longevity study to help determine how clinical decision-making skills were acquired. writers
commonly discussed her applicability in development of protocols for orientation of new nurse
graduates (mcewen & wills, 2011).
• one article described the importance of mentors during professional transition to an expert in the
oncology setting (dest, 2008).
• she cited the process from novice to expert and explained the personal steps she accomplished with
the help of mentors along the 24 year journey. research shows 83% of influential nurses have been
mentored (dest, 2008).
• her journey involved expert mentors seeing something in her she didn’t see in herself, encouraging her
to go back to school where she became an oncology nurse practitioner
 PRACTICE APPLICATION BENNER’S
MODEL
• has been used in the nursing profession to make innovative changes in how knowledge is acquired and
developed, continuing education’s rationale, and serve as a foundation for how nurses build and improve
skills
based on acquiring experience (benner, 1984).
• benner’s model may be helpful to the current problem of CLABS is by application to education.
• performance and learning needs of staff nurses can be identified and classified based on her five levels of
skill acquisition.
• this process can serve to identify experts that could serve in a teaching and mentoring role to those staff
members that are still in the novice to beginner phase.
• having an understanding of the skill level of each nurse would better prepare the nurse in the educator role.
• education of staff is an ongoing process that should never cease.
• Provide safe, effective care for central lines, staff must be proficient in caring for tubing,
needleless connectors, dressings, and have proper technique for medications infusions,
blood withdrawals, blood culturing, and flushing.
• Additionally, they must be trained and proficient in assessing for infection, occlusion
management, removal, proper tip location, and patient/family education.
• Acquiring this set of skills and knowledge takes time and mentoring. learning this skill
set will help the clinician become one that not only “knows that” but “knows how.”
• Often, a problem in facilities that lead to contamination of central lines is a lack of
knowledge and lack of compliance to policies that are designed to prevent infection
through proper care and maintenance of central line catheters.
• Implementing a training and competency model based on benner’s concepts could
help
to give the structure needed for a successful CLABSI prevention program.
 PRACTICAL
• Expert nurses have the APPLICATION
ability and “know how” to mentor those in need of proper skill
and
knowledge.
• These nurses also could stay up to date with best practice by serving on key committees and
being active members of key professional organizations such as the association for vascular
access (AVA), infusion nurse society (INS)
• Skills necessary for proper care of central lines need to be taught through demonstration.
• Benner’s concept of reflection can be used to bridge the gap between theory and actual skill.
• This can be appropriate for nurses and patient families performing a return demonstration,
further proving they have the knowledge and know how when faced with a situation or task
(1984).
• Deeper meaning and skill can be enhanced by reflection in practice, leadership, and education
 CONCLUSIO
N:
• Nursing practice guided by the human becoming theory live the processes of the
parse practice methodology illuminating meaning, synchronizing rhythms, and
mobilizing transcendence
• Research guided by the human becoming theory sheds light on the meaning of
universal humanly lived experiences such as hope, taking life day-by-day, grieving,
suffering, and time passing
 REFEREN
CES
• GEORGE B. JULIA , NURSING THEORIES- THE BASE FOR PROFESSIONAL NURSING
PRACTICE , 3RD ED. NORWALK, APPLETON AND LANGE.
• WILLS M.EVELYN, MCEWEN MELANIE (2002). THEORETICAL BASIS FOR NURSING
PHILADELPHIA. LIPPINCOTT WILLIAMSAND WILKINS.
• MELEIS IBRAHIM AFAF (1997) , THEORETICAL NURSING : DEVELOPMENT AND PROGRESS 3RD
ED. PHILADELPHIA, LIPPINCOTT.
• TAYLOR CAROL,LILLIS CAROL (2001)THE ART AND SCIENCE OF NURSING CARE 4TH ED.
PHILADELPHIA, LIPPINCOTT.
• POTTER A PATRICIA, PERRY G ANNE (1992)FUNDAMENTALS OF NURSING –CONCEPTS
PROCESS AND PRACTICE
3RD ED. LONDON MOSBY YEAR BOOK.
 REFERENCES
• ….. BASIS FOR NURSING (3RD ED.). PHILADELPHIA, PA:
MCEWEN, M & WILLS, E.M. (2011). THEORETICAL
LIPPINCOTT
• WILLIAMS & WILKINS.
• NOVICE TO EXPERT (2013, SEPTEMBER 16). NOVICE TO EXPERT: THE DREYFUS MODEL OF SKILL
ACQUISITION.
• RETRIEVED FROM HTTP://WWW.SLD.DEMON.CO.UK/DREYFUS.PDF
• NURSING THEORIES (2013, SEPTEMBER 16). FROM NOVICE TO EXPERT – PATRICIA BENNER.
RETRIEVED FROM
• HTTP://CURRENTNURSING.COM/NURSING_THEORY/PATRICIA_BENNER_FROM_NOVICE_TO_EXPERT.H
TML
• STANDING, M. (2007). CLINICAL DECISION-MAKING SKILLS ON THE DEVELOPMENT JOURNEY FROM
STUDENT TO
• REGISTERED NURSE: A LONGITUDINAL INQUIRY. JOURNAL OF ADVANCED NURSING, 60(3), 257-269.
• VITAL SIGNS: CENTRAL LINE--ASSOCIATED BLOOD STREAM INFECTIONS --- UNITED STATES, 2001,
2008, AND 2009.
• MMWR: MORBIDITY & MORTALITY WEEKLY REPORT [SERIAL ONLINE]. MARCH 4, 2011;60(8):243-248.
AVAILABLE
• FROM: CINAHL PLUS WITH FULL TEXT, IPSWICH, MA. ACCESSED SEPTEMBER 8, 2013.
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ANALYSIS OF