Excellence and Power in Clinical Nursing Practice

Share a meaningful nursing encounter (2 to 3 pages) that takes your reader into the complexities of your nursing practice. Using the first-person (I), write a narrative (a story) about a recent or memorable nursing experience you have had. The term nursing practice experience is used broadly here to include practice related to direct patient care, educational and managerial practice with colleagues.

Write your story with yourself as the main character telling the story; tell your reader how the situation was experienced by you. Take us into your world — the context of your surroundings, the nursing concerns you attended to (aspects of the patient/colleague experiences), your nursing responses/actions (or non-actions) and your emotions. Some ideas for the types of stories are identified below, but if you have any questions or are uncertain about how to proceed, please seek guidance from your instructor.

In her landmark book, “From Novice to Expert: Excellence and Power in Clinical Nursing Practice,” Dr. Benner tells us that nurses need both theoretical knowledge as well as practical knowledge in order to become experts in their field. Most disciplines place the focus on ‘know that’ knowledge (namely theoretical and academic knowledge), but Benner insists that the ‘know how’ knowledge of experience is even more important for a nurse, or for anyone involved in a health-care setting, since the nurse / practitioner learns from an accumulation of experiences and from trail-and-error. Benner (2001), too, posits 5 different levels of development that the health-care practitioner moves through: novice, advanced beginner, competent, proficient, and expert. Each one builds on the other as the nurse uses the reflection gained from her experience to improve her practice. Each of these five different levels constitute proficiency and skill not only in practical labor, but also in other components — such as skilled communication and mentoring — that are integral to the field of nursing.

The novice nurse, for instance, tends to see the patient as an object made up of discrete pieces of information / data and specific tasks that she, the nurse, has to master. The expert nurse, however, on the top of the rung, can move beyond that approaching her task in a more automatic fashion and seeing the patient as an individual who is worthy of and requires her full respect. At the same time, the expert nurse can effortlessly and diligently move through her tasks without being caught up in the technical details. The expert is able to transcend the tasks and patient to read the whole picture, but she ignores nothing else whilst doing so. Other responsibilities such as communication with patient, mentoring of, and interaction with other nurses, following physician instructions, and the other entire minutia involved with being a nurse are all performed in an expert, skilled manner. This is the domain of ‘intuition’.

Benner’s thesis reminds me of a challenging situation that occurred not too long ago between a patient and me.

It was in a nursing home. I had a long and tiring day. There was one patient that I had a tough time dealing with. She believed herself to contain ‘blue blood’ having been born and bred from a long line of British nobles — or so she told me and proclaimed to the others — and she believed that she deserved to be treated accordingly. I have always had a bias against such people. I am true, dyed-in — the wool democratic American who believes that all people are equal and that none should have preferable treatment. I have, therefore, often resented her uppity manner towards others and have found it difficult to ignore her slights and rebuffs to me.

That day had been a considerably stressful day: I had been reprimanded by the supervisor for a fault that I felt was not mine; I had had to assume a great deal of work due to the absence of some nurses; I was tired due to pressure at home; and I also had a run-in with a colleague. None of this was improved by my being called to the patient’s room in order to adjust her position in her bed. I did so, focusing on the tasks as required, and, being in Benner’s novitiate stage, and careful to please this particularly demanding patient, was taken up in concentrating on the details: move her carefully to one side, pull the sheet just so under her whilst not loosening my grasp; do it gently; etc. The patient, however, was not so docile. She kept on complaining and finally insulted me calling me a whore and denigrating my race. I bit my lip and reminded myself that Ms. X is an elderly lady who has little family to care for her and, therefore, needs particular care, and continued with my work. A few minutes later, however, the bell rang again with Ms. B summoning me to her room complaining that I had messed up her bed, that it was less comfortable than before, that she had never experienced such slovenliness yet in her life and that, if I were not to complete the job to her utter satisfaction, she would report me to the supervisor and ascertain that I were fired.

Close to tears now, I was about to turn on my feet and walk out when I remembered the recent scandal of 11 nurses in a nursing home in Britain who were found to slap, kick, sit on, and drench their patients with water at a Winterbourne View care home in Bristol (Robinson, 2012). Investigation demonstrated that the care workers were, generally, poor paid, uneducated, demotivated, and unable to gain entrance into other professions that they would have considered more ‘prestigious’ and that they would have preferred. The incident ruined their reputation forever. When reading the article, I had wondered how nurses could be brought to such lows of treatment, but I realized now that nurses could easily be brought to perpetrate such monstrosities by challenging patients such as MS. B. The challenge was to overcome it.

Without realizing it, I entered Benner’s expert stage. I deliberately perceived Ms. B as a patient. I told her that I would like to please her but did not know how and was upset that I consistently failed in pleasing her. She — I told her — knows her situation best, and if she could specify to me in a calm way exact requirements I would try to see them through. I said this to her in a calm and humorous way, and lo! Shortly we fell into a discussion of her past, of my stressful day as nursing (Ms. B. offered to give me some techniques), and we parted the best of friends. I used Benner’s concept of novice to expert here as examples here since both played a part in this incident. It instantiates the need for the importance of intuition in nursing (Tanner, 2006).. Benner (2001) states, “The expert nurse…has an intuitive grasp of each situation and zeroes in on the accurate region of the problem…” (p. 32). This is what I did and what I try to do every day. This is also in sync with Thompson (1999) who stressed the need for nurses to use the “middle ground” in decision making process by incorporating both the systematic (theory) and intuitive (practical) approaches into practice.

My experience above that illustrates stepping from the domain of novice to that of expert also reminds me of another concept that of unit environment and culture, and, specifically harmony that I attempt to achieve in that environment.

I regularly set goals for where I want to be and arrange mind and schedule to meet those goals. Misunderstandings do arise in life and especially in work, but I have taught myself, for the good of the environment and unit, to step back from the disagreement and to speak to the person into der to work it out. Rumors spread in our workplace, and people love gossip. One day, for instance, I was told that a certain nurse was gay. I attempt not to involve myself in personal lives, so when I heard the rumor I simply changed the subject. I also attempt to bring harmony to the patients. Another day, a woman with a cardiac attack mentioned that she was going for a cardiac cath. I comforted her, explained the procedure in depth and asked her if she had any particular concerns. The woman thanked me for my time and patience. It is in this way that I attempt to bring harmony to both my own practice and to the enveloping environment.

Part of being a Benner-sort of expert involves being a leader and mentor and requirements for this are superbly defined by the Robert Wood Johnson Nurse Fellows Program. The first and foremost requirement is self-knowledge in order to extend and develop one’s skills and know where one’s failings are in order to improve them. Mentors are also aware of their personal learning styles and are able to work well with a diversity of people. Another competency is interpersonal and communication effectiveness. Transformational leadership (which is stimulated by modeling and effective communication on the part of the leader nurse) is the highest structure of inspirational leadership that a nurse can maintain (Bass, 2008). By influencing and motivating followers, transformational leaders increases efficacy of the other. Similarly and counter-intuitively, transformational leadership may be more effective than so called passive leadership in influencing and instigating safety in the workplace. It is to that end; therefore, transformational leadership may be the best paradigm for the type of leadership that nurses should adopt.

For nurses, therefore, to make strides in the new century and to succeed in a world that is rife with stress and conflict, a new method is needed. Modern day nursing is different than the old in that it has new challenges and concerns. Nurses need to devise and learn new methods to deal with these challenges. Being passive learners is insufficient. Nurses also need to be leaders in order to deal with the novelty and challenges of their profession. Transformational leadership is a solution.

This essay, in conclusion, has helped me towards that end. It has not only provided me with a certain degree of self-knowledge, but has also made me feel better about my communication style and shown me that I am well on the way to progressing from novice to expert. I am in fact progressing towards my goal of becoming a transformational leader in my field.


Bass, BM (2008) The Bass Handbook of Leadership: Theory, Research, and Managerial Applications Simon and Schuster

Benner, P. (2001). Novice to expert: Excellence and power in clinical nursing practice. Upper Saddle River, NJ: Prentice Hall.

Robinson, M. (2012) Pictured: The 11 workers who admitted a campaign of cruelty, neglect and abuse against vulnerable patients in a care home from hell. Mail online. http://www.dailymail.co.uk/news/article-2184499/11-workers-admit-campaign-cruelty-neglect-abuse-aimed-vulnerable-patients-care-home-hell.html

Robert Wood Johnson Nurse Fellows Program. Available at: http://www.futurehealth.ucsf.edu/rwj/

Tanner, C. (2006). Thinking like a nurse: A research-based model of clinical judgment in nursing. Journal of Nursing Education, 45(6), 204-211.

Thompson C. (1999) Qualitative research into nurse decision making: factors for consideration in theoretical sampling. Qualitative Health Research 9, 815±828.

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