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8/18/2019 Beyond Expertise Theory, Practice and The
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Clinical Nursing 1997; 6: 93-97
G A R Y R O L F E BSc, MA, PhD, RMN, PGCEA
Principal
Lecturer
School of Health Studies University of Portsmouth Education Centre
St James Hospital Locksway Road Portsmouth P04 8LD UK
Accepted or publication 21 November 1995
S u m m a r y
• This paper reconsiders Benner's book
From Novice to Expert.
in which th
expert is portrayed as a reflective practitioner who works intuitively, drawin
almost unconsciously on a repertoire of context-specific paradigm cases.
• In the light of mo re recent writings on informal, practice -based theory, it is sug
gested that there is a sixth level beyond expertise which is characterized b
mindful practice and informal theory building. At this level, the practitioner con
structs informal theory out of practice, applies that theory back into practice, an
reflexively modifies th e theory as a result of the chan ged clinical situation .
• Seen in this way, theory and practice are two parts of the same process, and th
theor y-pra ctice gap is closed.
Keywords: expert practice, informal theory, reflection, reflexive practition
theory—practice gap.
From Novice to Expert (Benner,
the pinnacle to which nurses should aspire. Th is
0s, but in the light of later developm ents in our und er-
Benner suggested five levels of practice, from the novice
lized rule-governed procedu res, to the expert, who:
with an enorm ous backg round of experience, now has
an intuitive grasp of each situation and zeroes in on
conside ration of a large rang e of unfruitful,
alternative diagnoses and solutions. (Benner, 1984)
Nurs es are able to achieve this by drawing on 'past para
digm cases', that is, their experience of similar situation
which have proved successful in the past. Benner argue
that each expert nurse has his/her own situational reper
toire of paradigm cases which is unique to him/her, an
which constitutes a body of personal knowledge which i
very different from public, academic knowledge.
Benner, following the philosopher Gilbert Ryle (1963
referred to this knowledge as 'know-how', and distinguishe
between knowing ho w to do something, for example, t
personal, contextual, practical knowledge of how to respon
to a particular p atient following a bereave men t; and knowin
that something is the case, for example, the public, gener
izable, academic knowledge th at berea vem ent often follows
particular course. Another philosopher, Bertrand Russe
(1967) made a similar distinction between knowledge b
acquaintance, that
is,
from first hand experience, and know
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G. Rolfe
It is possible to possess either one of these types of
e other. For example, I migh t have the
Benner believed that it is possible, although not
In fact, the word 'experience' is misleading when used in
ens to us, whereas the kind of personal kn owledge
is is reflected in Ben ner's definition
difference to the ory '
experience is by reflecting o n it.
Partly due to Benner's work, reflection is now widely
the retrospective contem plation of practice
und ertaken in order to uncover the knowledge used in
a particular situation, by analysing and interpreting
the information recalled. The reflective practitioner
may speculate how the situation might have been
handled differently and what other knowledge would
have been helpful. (Fitzgerald, 1994)
Donald Schon (1983) referred to this as reflection-on-
rse has; if she does not reflect and learn from that ex peri-
Much of the personal knowledge generated fr
reflection-on-action is what Polanyi (1962) called t
knowledge; knowledge which cannot easily be put
words, or even knowledge which nurses are unaware
they possess. Benner referred to nursing actions based
personal, tacit knowledge as 'intuitive grasp', a process
which the nu rse just seems to know the righ t thing to d
any given situation. However, intuition is not a mag
process, but the u nconscious workings of
a
prepared m
and 'intuitive grasp should not be confused with mystic
since it is available only in situations where a deep ba
ground understanding of the situation exists ' (Ben
1984).
Expertise, then, is concerned with working intuitiv
with responding to practice situations holistically from
body of personal, tacit knowledge, a repertoire of past pa
digm cases, what has been called the art of nurs ing. Drey
and Dreyfus, on whose work Benner based much of
study, described this expertise in terms of the experien
performer, who:
is no longer aware of features and rules, and his/he
performance becomes fluid and flexible and highly
proficient. T h e chess player develops a feel for th e
game; the language learner becomes fluent; the pilo
stops feeling that he/she is flying the plane and
simply feels that he/she is flying. (Dreyfus
Dreyfus, 1977)
This notion of 'getting the feel' for an activity, of be
able to do it almost without thinking, will be familiar to
experienced car drivers or typists, and is referred to by p
chologists as 'chu nk ing' . C hun king is the process by wh
larger and larger units of behaviour or cognition come to
seen holistically as a single tho ug ht or action :
To the novice, typing proceeds letter by letter; to th
expert , the proper units are mu ch larger, including
familiar letter groupings, words and occasional
phrases. Similarly, the beginning driver laboriously
struggles to harm onize clutch, gas pedal, steering
wheel, and brake, to the considerable terror of
innocen t bystanders. After a while, those m ovemen
come quite routinely and are subsumed under muc
higher (though perhaps equally dangerous) chunks
behaviour such as overtaking ano ther car. (G leitma
1991)
Thus, 'much of the difference between master
apprentice is in the degree to which subcomponents of
activity have been chunked hierarchically' (Gleitm
1991).
When applied to nursing, the chunks take the form
sets of procedures o r gro ups of related past paradigm ca
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Theo ry, practice, and th e reflexive p ractitioner
9
its concrete referents
ly be pu t into ab stract principles or even explicit
1984).
The expert nurse
is
therefore
a
reflective practitioner
and
paradigm cases,
and
oothly and unconsciously translates that knowledge
aying an intuitive grasp of whatever situ -
on he /she finds him /herself in.
is, however, not the only form of
a process which he called
in which reflection takes place in the
In reflection-
nformal theory about the situation they find themselves
the possible outcomes of
out their hypotheses in practice,
on the changes that this produces, respond to those
by modifying their theory, test their new hyp othe-
and so on in a reflective cycle (Fig. 1). Fu rthe rm ore , all
in the p ractice setting so quickly and seam-
to become a single process. Reflection-in-action is
a form of problem-solving, which is why it was
so referred to by Schon as on-the-sp ot experimenting.
Benner hinted
at
this process when she wrote: 'expertise
the
clinician tests
and
refines propos itions,
and
principle-based expectations
in
actual
she did not
of
the nurse's role, despite
the
the
problem-solving approach characteristic
of
is
evident
in
several
of the
paradigm
es recou nted
by
Benner
in her
book.
For
example,
she
EXPERIENCE
CTIVE
OBSERV TION
REFLECTION
GENER LIZ TION
CONCEPTU UZ TION
presents an account by an expert nurse who discovers
patient lying in a pool of blood:
So
I
looked
at
the dressing and
it
was dry, the blood
was coming out of his mou th. Th e m an had a
tracheotomy because of the type of surgery that had
been don e. He also had an
NG
tube
for
feedings, an
I got to thinking that
it
might be the innom inate
or
the carotid artery that had ero ded. So we took him
o
the ventilator to see if anything was going to p um p
out of the trach . Th ere was a little blood, but
it
look
mostly like
it
had come down from the phary nx in to
the lungs. So we began hand ventilating him , trying
to figure out what the devil was inside his mo uth that
was pum ping out this tremendou s amo unt of
bl oo d.. . (Benner, 1984)
Benner noted the expertise with which the nur
handled the situation, but neglected to explore the way tha
she formulated and tested hypotheses in an attemp t to solv
the problem of where the blood was coming from. Th
nurse in this example was clearly engaged in reflection-
action, although Schon's book The
Reflective Practiti
would have been published too late for Benner to empl
his terminology.
The significance of reflection-in-action is not just tha
solves problems for practice, but that it does so through th
construction of informal theories which are being con
stantly tested, m odified, retested , and so on in a process
on-the-spot experimenting.
In
fact, this n otion
of
inform
theory, which refers to personal, individual theories abo
specific patien ts in specific situations, is arguably o ne of t
most important concepts for nursing to emerge over th
past 10 years, although it was first employed by educatio
alists (Usher Bryant, 1989).
Furthermore,
the
relationship between informal theo
and practice
is
rather different from that between form
scientific theory and practice. Formal theory informs an
dictates to practice, in the sense that a nurse using a p art
ular counselling model will be following a particular tem
plate or process. Informal theory and practice are mutua
dependent, however, and follow a circular process, w
practice generating theory, theory modifying practic
which generates new theory and so on. The pract
emerging from this process will be referred to as reflex
practice, as it not only generates new theory, but is its
reflexively m odified by tha t theory.
Carr Kemmis (1986) pointed out that informal the
is contained in practice by definition, because without
practice is merely rando m and uncoordinated activity, an
informal theory
is
similarly
by
definition generated fro
practice. Informal theory and practice, then , are not o
8/18/2019 Beyond Expertise Theory, Practice and The
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96 G. Rolfe
this has a number of important implications for nursing,
not least of which is the way in which the generation and
application of informal theory ab olishes the hierarchical
relationship between theory and practice and between
researchers and practit ioners, and hence closes the theory-
practice gap (Rolfe, 1993).
Beyond expert ise:
th
reflexive practit ioner
The exper t or reflective practitioner makes practice seem
so simple
and
effortless b ecause he /s he
is
functioning
on
autopilot, unconsciously drawing on his/her reper toi re of
paradig m cases. However, for the reflexive practitioner who
is concerned with reflection-in-action, with on-the-spot
experimenting and with the generation of informal theory
an d the testing of hypotheses in the practice situation, it is
vitally imp ortant that he /sh e is acutely aware of the clinical
situation he/she finds him/herself in, and this requires
h i m / h e r to go beyond expertise as it is described here.
In fact, this sixth level of practice is almost the antithesis
f expertise. The aim of an expert is to act intuitively and
without conscious thought, almost at spinal cord level, and
' if experts are made to attend to the part iculars . . . the i r
performance actually deteriorates' (Benner, 1984). But
there are equal dangers in not attending to p articulars:
as a practice becomes more repetitive and routine,
an d
as
knowing-in-practice becomes increasingly tacit
and spontaneous,
the
practit ioner may miss
important o ppor tuni t ies
to
think abo ut what
he is
doing. He may find th a t . . . he is drawn into patterns
of error which
he
cannot co rrect.
And
if he learn s,
as
often happens, to be selectively inattentive to
phenomena that do not it he categories of his
knowing-in-action, then he may suffer from bored om
or 'burn ou t ' and afflict his clien ts w ith the
consequences of his narrowness and rigidity. W hen
this happens, the practition er has 'over-lea rned' w hat
he knows. (Schon , 1983
The reflexive practitioner, in contrast , requires a part ic-
ular sort of mindfulness which involves an intense concen -
tration on the task at hand. Even with very simple tasks
such as wound dressing, the difference is striking: the
expert nurse would perform the requ ired actions swiftly
and deftly and without conscious thought, whereas the
reflexive practitioner would think about every move, every
decision, relating them to this patien t in this situation .
More importantly, nurses would be learning from their
performance, thinking about
how it
could
be
don e differ-
ently, constructing theories, testing hypotheses,
and
modi -
fying their actions in the here-and-now, and this requires
focus the attention of nurses on the here-and-now and
the uniqueness of their individual relationships with
of their patien ts,
and
reduces the possibility of the bore
and burn out that comes from ov erfamiliarity with th e
to be performed.
Reflexive practice in act ion
Reflexive practice is difficult to pin down for two rea
firstly because its com pone nts blend together into
smooth operation and secondly because, unlike reflec
o«-action, it takes place
in
vivo in live, real-time pra
situations. However, by reflecting on reflection-in-actio
can be seen to comprise of a number of discrete elem
(Fig. 2 which include:
• reflecting on the clinical situation in order to bu
body of personal knowledge about this patient in thi
uation;
• constructing an informal theory based primarily on
informal knowledge, but also on past parad igm cases
formal, research-based theory;
• formulating a hypothesis from the informal theory;
• testing the hypothesis by making a clinical in tervent
• reflecting on the transform ed clinical situation and m
ifying or adding to the body of personal knowledge;
• constructing a new informal theory, and so on.
In order to see how reflexive p ractice wo rks, let us
the example
of
a
terminally
ill
patient who asks
the
nur
he is dying. The re are many possible reasons why a pa
would
ask
such
a
question, ranging from
a
need
for
fa
PR CTICE
ypothesis
testing
eflectio
HYPOTHESIS
REPERTOIRE
P R DIGM
C SES
PERSON
KNOWLEDG
ypothe sing
INRDRM L THEORY
Theory
constructi
FORM L THEORY
EMPIRIC L RESE RCH
8/18/2019 Beyond Expertise Theory, Practice and The
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The ory , practic e, and the reflexive prac tition er 9
no t dying,
ons with other patients.
Although this personal knowledge will provide the main
Having constructed an informal theory about this
personal knowledge, and so on.
This is primary nursing in its truest sense, and requires
an intimate knowledge of the patient's physical condition
psychological make up and social situation that can onl
come from a sustained therapeutic relationship. It als
requires the nurse to be able to think on his/her feet an
synthesize personal, academic and scientific knowledg
into a unique informal theory which can be immediatel
tested out and modified. And because the theory is reflexiv
to subsequent changes in the clinical situation, there is n
hint of
a
gap between theory and practice. Indeed, they a
two sides of the same coin, and as such, are impossible t
separate. Theory and practice are one, and the reflexiv
practitioner is both researcher and theory-builder.
R e f e r e n c e s
Benner P. (1984)
From No vice to Expert.
Addison-Wesley, CA.
Carr W. Kem mis S. (1986) Becoming Critical. Falmer Pre
London.
Dreyfus H. L. Dreyfus S.E. (1977) Uses and abuses of multi-attribu
and multi-aspect model of
decision
making. Unpubl ished m an
script, Department of Industrial Engineering and Operation
Research, University of California, Berkeley.
Fitzgerald M. (1994) Theories of reflection for learning. In
Reflectiv
Practice m Nursing (Palmer A., Burn s S. Bulman C , ed
Blackwell Scientific Publications, Oxford.
Gleitman H . (1991) Psychology. Norton, New York.
Polanyi M. (1962) Personal Knowledge: Towards a Post-critica
Philosophy. Routledge Kegan Paul, Lon don .
Rolfe G. (1993) Closing the theory-practice gap: a model of nursin
praxis. Journal of Clinical Nursing 2, 173-177.
Russell B. (1967) The Problems of Philosophy. Oxford Universi
Press, Oxford.
Ryle G. (1963) The Concept of Mind. Harmondsworth. Pengui
Harmondsworth.
Schon D.A. (1983) 77?^ Reflective Practitioner. Temple Smi t
London .
Usher R. Bryant I. (1989) Adult Ed ucation as Theory Practice an
Research. Routledge, London.
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