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Running head: PRACTICAL KNOWLEDGE AND BENNER’S DOMAINS
Practical Knowledge and Benner’s Domains of Nursing Practice
Yendi Gomes
Georgia Baptist College of Nursing of Mercer University
Nursing 420 Leadership Practicum
Pledged__________________________________
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Practical Knowledge and Benner’s Domain of Nursing Practice
Practical knowledge is an important aspect of nursing care. It is needed to make nursing
judgment based on critical thinking. Today, nurses in education and practice settings are
encouraged to use critical thinking skills to make decisions, or to solve problems. Critical
thinking is defined as a process by which an individual uses multiple data, both scientific and
non scientific, to make a decision. The level of critical thinking an individual utilizes depends on
the task, the setting, and the individual’s knowledge, skills, and memory. Critical thinking skills
range from basic to complex. One element of critical thinking is intuition (Ruth-Suhd, 1997).
In her ground breaking work, Benner (2001) found that critical thinking skills varied
with the level of nursing proficiency. She found that nurses gained knowledge in stages by
experience. These stages were the novice stage, the advanced beginner stage, the competent
stage, the proficient stage, and the expert stage. She also found that intuition was a characteristic
of an expert nurse. Her work focused on the expert knowledge of “know-how,” which is intuitive
knowledge that is gained over time and with experience. She stated that this knowledge allows
the nurse to make decisions quickly without wasteful consideration of a large range of unfruitful
alternatives, diagnoses, and solutions. She discovered 31 nursing competencies that she classified
into seven domains of nursing practice. She encouraged nurses to write about their experiences
so that it will exemplify excellent nursing practice.
I am writing about a memorable experience with a patient that I think received excellent
nursing care. I do not consider myself an expert nurse, but I do think I give good nursing care. In
critical care areas such as the emergency department (ED) where patients are unstable and their
conditions can rapidly deteriorate, the nurse at the bedside needs both practical knowledge
(know-how) and theoretical knowledge (know-that) to make rapid decisions in crisis situations.
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The call came about 2:30pm over the radio as a motor vehicle accident (MVA) on
Interstate-285 involving two cars. The ED was going to receive passengers from both cars. One
of the cars in the accident had a father and his son who were both being transported to the ED in
the same ambulance. The child was ten years old. The ED is neither a trauma nor a pediatric
facility. We were told by the emergency medical technicians (EMTs) that the accident was
minor. According to the Emergency Medical Treatment and Active Labor Act (EMTALA, 1986)
the ED had to accept both patients. The ED has the responsibility to assess, stabilize, and if
needed to transfer the patients to the appropriate facility (American Academy of Emergency
Medicine, n.d.).
On arrival to the ED the father was ambulatory and sent to the front triage area. I
received the ten-year old son directly via stretcher in one of the treatment rooms. He was
immobilized on a back board and a cervical collar was around his neck. The report I received
from the EMTs in the room was that the child was restrained in the front seat. The impact of the
collision was on the front-end of the driver’s side without intrusion to the door. The EMTs stated
that he had vomited once and attributed it to the bumpy ambulance ride. I went over to talk to the
child. He was quiet and seemed to have difficulty focusing his eyes.
While looking at him I felt something was wrong. He was ten years old and acting too
calm for the situation. I quickly obtained vital signs which were stable. I performed a quick head
to toe assessment; there were no visible injuries and he denied pain. His skin was warm and dry
and his oxygen saturation (O2 sat) level was at a 100%. His eyes were opened, he did not seemed
scared, just too relaxed. He knew who he was, where he was, and what had happened. He told
me his name was T.R. and that he and his father were on their way to a baseball game when the
accident occurred. He would look at me and his eyes would occasionally flutter and close, then
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he would open them again. I had a feeling that something was not right. I had a feeling that he
had a head injury and that his condition could deteriorate rapidly. Ruth-Sahd (1997) stated that
intuition is a type of knowledge that is often gained without conscious recognition of what data
were used to reach this decision, or an understanding without rationale. 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). Perhaps this was what was happening. There was another nurse in the
room and I told her to get the ED doctor to the room. I decided to start an intravenous line and
draw blood for lab testing. I recognized two of Benner’s domains of nursing practice being
demonstrated here, the administering and monitoring of therapeutic interventions and regimens
and the diagnostic function of the of the nurse.
The ED doctor came into the room. He looked at the T.R., the monitor, and read T.R.’s
history. He asked T.R. some questions and examined him quickly. The doctor did not seem too
concerned. He took T.R. off the back-board but left the cervical collar in place and ordered a
cervical spine x-ray. I told him that I was concerned that T.R. was not acting appropriately and
that he probably had a head injury. I suggested that T.R. probably need a CAT scan of his head.
The doctor said “fine”. I got on the telephone with the CAT scan technician and told him that a
CAT scan was needed immediately. Benner’s domain of monitoring quality health care was
utilized here. Getting appropriate and timely responses from physicians is one of the
competencies.
I decided to go with T.R. to CAT scan. I wanted to be with him just in case something
changed. On the way to CAT scan I kept on talking to him, asking him if he was having any
pain. He just looked at me and shook his head. Reed (2003) mentioned that knowing begins with
the attention given to the patient and not just gathering information for assessment. It is an
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application of knowledge gained through various experiences so care can be enhanced. One of
Benner’s domains was also exhibited in this situation “the helping role”. Benner (2001) stated
that a person can receive help without asking for it. She describes this as presencing, being with
the patient. Even though T.R. did not verbally ask me to be with him, I knew that I had to be
with him.
While in the scanner I kept looking at T.R. through the glass as if to detect any visible
signs of change. The CAT scan technician looked at me and said “there it is: a bleed.” I said to
the technician that I knew something was wrong. I felt sad but I still had hope. T.R was young
and strong and with rapid intervention he could do well. I could not wait for the scan to be done
so I could go to his side. After the scan was done I walked quickly to his side and started talking
to him. I noticed that he was not responding verbally any more and that his eyes were closed. I
needed to get him back to the ED quickly. The domain identified here by Benner is effective
management of a rapidly changing situation and the ability of a nurse to identify and manage a
patient in crisis.
On the way back to the ED I met up with the ED doctor who was coming to find me. He
said that T.R. had a large subdural hematoma with multiple skull fractures. He asked me how
T.R. was doing and I told him that he was not responding verbally at all, but was responding to
pain. We got T.R. into the room and noted that he was deteriorating rapidly. His heart rate was
slightly elevated at 110, his skin was flushed, and he had dropped his O2 sat to about 80%. I
knew that he needed intubation to protect his airway and to provide adequate oxygenation, so I
called for help. This is another illustration of Benner’s domain the effective management of
rapidly changing situation. She stated that skilled practice includes the ability to grasp the
problem quickly, to intervene appropriately, and to assess and mobilize the help available.
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In a few minutes the room was full of practitioners ready to help. T.R. was intubated and
sedated using a treatment modality called rapid sequence intubation. With this treated the nurse
has to administer medications that would sedate and paralyze the patient making intubation easy.
I was the medication administration nurse. I knew that I had to give T.R. the accurate dose of
medication that was ordered. These are medications that are usually given by an anesthesiologist.
Benner’s domain of administering and monitoring therapeutic interventions and regimens was
illustrated here. In this domain one of the competencies is to administer medications accurately
and safely.
After intubation T.R.’s vital signs stabilized and his O2 sat went up to a 100%. I
continued to assess and monitor him, looking to detect the slightest change in his condition. The
doctor stated that he had spoken to the neurological surgeon and that T.R. needed surgery
immediately to evacuate the blood that was building up in his brain.
I asked the doctor if any one had spoken to T.R.’s parents. He said that he had briefly
spoken to the mother and that the father was being cared for in another area of ED. He told me
that it was okay for the mother to come back to the room. When she came back to the room she
looked scared and was crying. She wanted to know if her baby was going to be okay. I went over
to her and held her hand. I told her that it was okay to talk to him and to hold his hand. I
explained to her why he was intubated and told her that his vital signs were stable. I also told her
that the neurologist will be coming in and that he will give her more detailed information about
the surgery. All she did was nod her head and sniffle. Henneman and Cardin (2002) stated that
the needs of family members of critically ill patients are well established; the need for
information, the need for reassurance and support, and the need to be near the patient. Benner
(2001) also talked about this as being a domain of the teaching-coaching function. One of the
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competencies in this domain is to provide an interpretation of the patient’s condition and give
rationale for procedures.
T.R was ready for surgery with in 20 minutes of arrival to the ED. The operating room
nurse and the surgeon were down to take the patient. I stood by T.R.’s mother holding her hand
while the neurologist told her about the procedure, listening carefully so that I may be able to
answer any questions that she may have later. Benner (2004) stated that comforting a patient
includes providing social, emotional, physical, and spiritual support that is needed for that
patient. The neurologist told her that because we acted quickly, he is probably going to be fine. I
felt my spirit lift a little. It seemed much longer than 20 minutes that T.R. had been in the ED.
His father had decided against treatment and wanted to be his son and wife. I said goodbye to
T.R. and he was taken to surgery.
When T.R. was gone I looked around the room, empty packages wrapping on the floor. I
felt good about the turn of events. I had given good care to my patient and that probably will
make a difference in his prognosis. The ED doctor and nurses that were around came up to me
and stated “good call.” A few hours later the neurologist called the ED and stated that the surgery
went very well. Benner (2000) stated that clinical judgment requires moral agency (the ability to
affect and influence situations), relationship, perceptual acuity, skilled know-how, and narrative
reasoning about particular patient transitions.
Benner’s theory is applicable in this patient situation in that I used intuition or “gutfeeling to care for my patient. I do not consider myself to be an expert nurse, but a caring, and
attentive nurse. I am still evolving and learning as a nurse. Jones (2007) stated that many nurses
do not view themselves as experts because they are more willing to admit their need to learn than
lesser practitioners. Nurses should be encouraged to use their knowledge and experience in
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practice. Theoretical knowledge (know-that) and practical knowledge (know-how) should be
used together in practice. Thompson (1999) 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.
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