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


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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


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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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