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Novice to Expert: Through the Stages to Success in Nursing
By Sheila J. Leis, MS, RN-BC, and Rosalinda Alfaro-LeFevre, MSN, RN, ANEF
This course is 1 contact hour
Course must be completed by March 5, 2021
Goals and objectives: The goal of this program is to help nurses to use Benner's novice-to-expert model to coach nurses through various stages of competency development. After studying the information presented here, you will be able to:
  1. Describe Patricia Benner’s five stages of moving from novice to expert
  2. Discuss why it’s important to help nurses on their journey from novice to expert
  3. Identify strategies nurses can use to support one another as they develop competency in handling various clinical situations.

Nurse.com educational activities are provided by OnCourse Learning. For further information and accreditation statements, please visit Nurse.com/Accreditation. The planners and authors have declared no relevant conflicts of interest that relate to this educational activity. OnCourse Learning guarantees this educational activity is free from bias. See “How to Earn Continuing Education” to learn how to earn CE credit for this module or visit http://ce.nurse.com/instructions.aspx.
Florence Nightingale understood the importance of nurturing nursing competence long before it became a favorite topic of conversation in our profession. In letters she wrote, her passion for excellence in nursing shines through.
Maintaining a positive attitude and working to build mutual trust, Kelly helps Emily identify her learning needs. She frequently asks Emily how she's doing and whether she needs help. She monitors Emily's patients’ outcomes, and they discuss challenges and successes together.

Kelly assigns Emily to care for patients with similar conditions so she can improve her clinical reasoning skills. Kelly helps Emily identify priorities and points out complications that may occur in her patients. Emily attends a support group of new grad nurses at the hospital to discuss her experiences. Emily is surrounded by nurses who mentor and nurture her growth as a professional, competent nurse. She benefits from attending ongoing support group meetings. By the end of a year, Emily is happy in her position and well on her way to becoming a clinically competent nurse. But not all nurses have experiences like Emily’s. Too often, nurses find a gap between what they learned in schools and what they experience in the clinical setting.5 They find themselves in a “trial by fire” with no one to turn to help them with patient and practice dilemmas. This stress and lack of support causes job dissatisfaction and makes good nurses leave in search of greener pastures. We can’t afford to lose good nurses simply because they aren’t given the support that every new nurse needs to become a good clinician. From patient care perspectives and from moral and professional perspectives, we owe it to our peers to help them grow and succeed. From a financial perspective, nurturing and retaining nurses is extremely important. Turnover costs are estimated to be between $42,000 for medical/surgical nurses and up to $85,000 for specialty nurses.6 One of the most useful frameworks for addressing nurses’ needs at various stages of professional growth is the model of the stages of clinical competence first described by Patricia Benner, PhD, RN, FAAN, in her classic book, “From Novice to Expert: Excellence and Power in Clinical Nursing Practice,” published in 1984, with a commemorative edition in 2001.7

Benner, along with coauthors Christine Tanner, PhD, RN, FAAN, and Catherine Chesla, DNSc, RN, FAAN, expanded on these themes in the second edition of their book “Expertise in Nursing Practice: Caring, Clinical Judgment, and Ethics.”8 The Benner model help nurses gain insight into how nursing expertise develops and what needs to be done to nurture new nurses through clinical challenges.
Benner describes the following five stages of competency development: Stage 1: Novice. Beginners have no experience with the situations in which they are expected to perform. They learn “context-free” rules to apply universally. For example, “Check the blood pressure every hour. If the diastolic is over 100 mmHg, call the physician.” But rules can’t tell a novice which tasks to perform in each actual situation, so behavior in the clinical setting is limited and inflexible.

Novices have very limited ability to predict what might happen in a particular patient situation. It’s not unusual for novices to miss subtle signs and symptoms that indicate a change in condition until after they’ve had experience caring for several patients with similar symptoms.7,8 Stage 2: Advanced beginner. Nurses with this level of proficiency have had enough experience to note recurring, meaningful components of a situation. The advanced beginner begins to formulate guidelines that dictate actions. They are new grads in their first job. They have “knowledge, skills and know-how but don’t have many in-depth encounters with a similar patient population,” Benner says. Stage 3: Competent. These nurses begin to see their actions in terms of long-range goals and plans. Competent nurses lack the speed and flexibility of proficient nurses but have a feeling of mastery and can rely on advanced planning and organizational skills. They have an increased sense of salience, meaning they know what important signs and symptoms to look in various patient circumstances.

They begin to recognize patterns and the nature of a clinical situation more quickly and accurately. They have better "hunches" and need to examine fewer options to make decisions. Stage 4: Proficient. The nurse views situations as “wholes” rather than parts. Maxims (general rules and principles) and reflecting on nuances (subtle differences in a situation) guide performance. Proficient nurses learn from experience what events typically occur and how to modify plans accordingly. They see goals and salient facts, but still must deliberately make decisions. Stage 5: Expert. Thanks to a well-developed ability to recognize demands, identify resources, and attain goals, experts know what needs to be done for each of their patients. They no longer rely solely on rules, guidelines, or maxims to connect understanding of a situation to the appropriate action. They have an intuitive grasp of each situation based on their deep knowledge and experience.

They focus on the most relevant problems, not irrelevant alternative options. They use analytical tools only when they have no experience with an event or when events and behaviors don’t occur as expected. The expert often “just knows” a particular situation without internal analysis. For an idea of the range, consider this example from Benner: Beginning nurses focus on tasks, such as checking vital signs; they basically have a “to do” list. Experts focus on the whole picture even when completing tasks. For example, they may be emptying a Foley catheter and notice subtle changes, such as the patient seems harder to arouse than in previous encounters.
Advanced beginners
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This continuing education course is FREE ONLINE until January 26, 2019, courtesy of Nurse.com. To take the test for FREE, go to https://www.nurse.com/ce/novice-to-expert-through-the-stages-to-success-in-nursing. After that date, you can take the course for $12 at the same link. If you have a CE Direct login and password (generally provided by your employer), please login as you normally would at https://cedirect.continuingeducation.com and complete the course on that system.
If the course you have chosen to take includes a clinical vignette, you will be asked to review the vignette and answer 3 or 4 questions. You must answer all questions correctly to proceed. If you answer a question incorrectly, we will provide a clue to the correct answer.
Once you successfully complete the short test associated with the clinical vignette (if there is one), proceed to the course posttest. To earn contact hours, you must achieve a score of 75%. You may retake the test as many times as necessary to pass the test.
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In support of improving patient care, OnCourse Learning is jointly accredited by the Accreditation Council for Continuing Medical Education (ACCME), the Accreditation Council for Pharmacy Education (ACPE), and the American Nurses Credentialing Center (ANCC), to provide continuing education for the healthcare team.
OnCourse Learning is also an approved provider by the Florida Board of Nursing, the District of Columbia Board of Nursing, and the South Carolina Board of Nursing (provider # 50-1489). OnCourse Learning’s continuing education courses are accepted by the Georgia Board of Nursing. OnCourse Learning is approved by the California Board of Registered Nursing, provider # CEP16588.
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While many nurses consider new RNs in their first year of clinical practice to be novices, Benner and her colleaguess write that the novice stage “typically occurs in the first year of students’ clinical education. Novice nurses tend to learn through formal mechanisms, including review of policy or procedures, attendance at simulation experiences, or role playing with experienced facilitators.12 These nurses function at basic levels and need significant supervision and specific directions. Once students graduate from school and pass NCLEX, Benner says they are no longer novices: “No one can get through nursing school and take the NCLEX-RN while remaining a novice!”8
Advanced beginners, typically new graduates, are beginning to intuitively observe elements of situations. They set priorities in linear ways and can be overwhelmed when they perceive all interventions to be equally important.13 (Level B) They can’t yet see the bigger picture.

Nurses at this stage need experience so they can recognize aspects, such as signs and symptoms that they may have only studied in the classroom. Nurses need to understand that novices will never get enough experience-based knowledge in school. “They couldn’t be in school long enough to do that,” Benner says.10 “They develop that knowledge on the job.”

For this reason, Benner, her colleagues and many educators today recommend a new-grad residency program of at least one year. The program should include coursework, mentoring, and use of clinical narratives to help nurses reflect on and learn from their experiences.7

A clinical narrative is a first-person “story,” written by a clinician, that describes a clinical situation (e.g., how a nurse managed a patient with signs and symptoms of heart failure). Narratives help nurses to analyze situations, reflect on their clinical practice, raise their consciousness about their knowledge, and share their experiences with others.7,8 It’s best to initially limit advanced beginners to working with patients with a narrow range of conditions so they aren't overwhelmed with too many patient conditions and can focus on developing competency in caring for certain patient populations. Frequent clinical rotation isn’t recommended because it makes it difficult for nurses to hone their ability to recognize patterns within similar patient populations.7

With frequent clinical rotation, nurses are also less likely to develop in-depth clinical knowledge of specific conditions because they have the “brain drain” of dealing with the “newness” of the various units. Benner recommends that preceptors of advanced beginners forecast what can be expected because these nurses haven’t had opportunities to experience how clinical problems tend to progress. It’s difficult for them to predict complications and what may happen in the future. A preceptor might say, “With this complex leg fracture injury, I would be looking for compartment syndrome as a possible complication.” Advanced beginners also need help in articulating knowledge. Benner suggests that if you go into a room, and the nurse looks overwhelmed, don’t ask, "What can I do for you?" because they'll be too overwhelmed to stop and articulate what they need. Instead, just pitch in and help until the crisis passes.”7

Once it does, you can help the nurse identify what was important and not important in the situation. As you might expect, advanced beginners need help setting priorities. For example, preceptors may stress to new nurses caring for patients with respiratory distress that maintaining airway patency and monitoring ABG results are key care priorities. Feedback is important for new nurses and particularly for new grads, who are used to frequent feedback in school. Positive feedback, such as “You did a great job in getting Mrs. Jones to open up about what was bothering her,” builds confidence. Constructive criticism is also important. For example, “I noticed this patient assignment wasn’t easy for you. Can you think of some reasons why? Then we can talk about what I can do to help you.”

Read the full CE, including more about Benner’s strategies, online.
For example, several letters from 1861 refer to the need to provide training and to attract qualified candidates.1 However, Nightingale also knew that completing a basic nursing education didn’t guarantee competency years later and even recommended that nurses receive certificates for recent experience, a concept analogous to today’s continuing education.2

As our profession evolves, competency in rapidly changing healthcare settings remains a key component of excellent nursing care. Competency is at the heart of patient safety, satisfaction, and clinical outcomes in any healthcare setting whether in acute care, home health, assisted living, or skilling nursing. It's also key to retaining good nurses because it gives them the confidence they to succeed.

But developing competency is only one step to becoming an expert nurse. Nursing proficiency grows over the years — a product of experiences. This module addresses how expertise develops from novice to expert and how to support one another during this challenging journey. A well-thought-out orientation program is the key to getting off to a good start. Many organizations now also have nurse residency programs to facilitate the integration of newly licensed RNs into professional practice roles through competency development.3,4 Consider the case of Emily. An excited new nurse grad, Emily reports to duty at her first job: a med/surg staff nurse in a large hospital. Full of hope and confident the hospital is the right fit, Emily meets her new coworkers and Kelly, her preceptor, who has worked in med/surg for seven years.
Benner’s stages of clinical competence
The Dreyfus Model of Skill Acquisition forms the foundation for Benner’s work. Hubert and Stuart Dreyfus developed their model based on their study of chess players, Air Force pilots, and Army commanders and tank drivers.9 (Level B) They contend that expertise is based on experiential learning (learning through reflection on experiences) and situated learning (learning that’s situation-based).

Learning in actual hands-on situations is essential for progressing from a novice to expert in any field.7,8 Benner found parallels in nursing, where improved practice depends on both science and experience. She writes, “At the heart of good clinical judgment and clinical wisdom lies experiential learning from particular cases.”7

All of us who have nursing experience can remember patients who taught us important lessons. Developing clinical wisdom takes time. Experiential learning requires an engaged learner who is open to growth and development over time.7 Benner and her colleagues say that as nurses are engaged in various situations, and learning from them, they develop skills of involvement, meaning that they know how close or distant to be with patients and families in critical times of threat and recovery.7,8

These skills are essential for nurses to manage the stress that comes with their careers. Faced with an emotionally challenging patient, an overprotective parent, or a relative who disagrees with a loved one’s end-of-life decision, nurses must know how to handle the situation to meet the person’s needs while not losing themselves in the process. Completing the rite of passage from novice to expert isn’t a forgone conclusion. In a telephone interview with Benner, she explained that nurses can gain knowledge and skills (“knowing how”) without ever learning the theory (“knowing that”), which brings expertise.10 Benner’s model has been described as having a significant impact on nursing practice, as well as being applicable to any adult learning situation, including mature adults who are entering nursing as a second career.11 As nurses develop expertise, particular changes in performance occur. The abilities of a new nurse develop from behaviors guided by rules, to the ability to see the “big picture” to a nurse who responds by intuition in a fluid and seamless manner.2 According to Benner, as expertise grows, nurses move from reliance on abstract principles (principles that may not be practical in the current situation) to applying knowledge from concrete experiences in the past (they remember a similar patient that had similar issues).

They move from viewing a situation in bits to viewing it as a whole. They are involved performers, rather than detached observers.11 These cumulative experiences help nurses move through the five stages. The following is a closer look at strategies that help nurses progress through Benner’s five stages. As you consider the strategies, remember that nurses who change practice areas may revert to earlier stages of expertise. For example, an expert nurse in the CCU would not be able to immediately function as an expert in the OR (although certainly the nurse’s expertise is valuable) or in home health.

Understanding this helps nurses deal with the anxiety and uncertainty associated with changing specialties. It also helps specialty nurses understand why a nurse with lots of experience may still need a lot of support.
Novice to expert
What does it take to become an expert nurse?
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EDITOR’S NOTE: Cynthia Saver, MS, RN, and Maureen Habel, MA, RN, past authors of this educational activity, have not had an opportunity to influence the content of this version. OnCourse Learning guarantees this educational activity is free from bias. Sheila J. Leis, MS, RN-BC, is a full-time nursing faculty member at Indiana Wesleyan University. She has more than 15 years of experience as a professional development specialist in a Magnet hospital. She has previous experience as a nurse manager and has been certified in medical/surgical nursing for more than 25 years. Rosalinda Alfaro-LeFevre, MSN, RN, ANEF, is president of Teaching Smart/Learning Easy in Stuart, Fla. She’s known nationally and internationally for her writings and programs on teaching critical thinking and improving personal and professional performance.
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