CARING, CLINICAL WISDOM, AND ETHICS IN NURSING
PRACTICE
PATRICIA SAWYER BENNER
 August 12, 1942
 first developed a model for the stages of clinical
competence in her classic book "From Novice to
Expert: Excellence and Power in Clinical Nursing
Practice".
 Her model is one of the most useful frameworks
for assessing nurses' needs at different stages of
professional growth
 Chief Faculty Development Officer for Educating Nurses,
the Director of the Carnegie Foundation for the
Advancement of Teaching National Nursing Education and
honorary fellow of the Royal College of Nursing.
5 LEVELS OF CAPABILITIES
1. NOVICE
 no background experience of the situation in
which he or she is involved.
 difficulty discerning between relevant and
irrelevant aspects of the situation.
 Nurse students; no experience; blank paper
2. ADVANCED BEGINNER
 In the Dreyfus model develops when the person can
demonstrate marginally acceptable performance
having coped with enough real situations to note, or
to have pointed out by mentor, the recurring
meaningful components of the situation.
 Still requires mentor or experienced nurse to
assist with defining situations, to set priorities,
and to integrate practical knowledge (English,
1993)
 Fresh grads; pinagtyatyagaan; 6-2pm 3:30uwi
3. COMPETENT
 The competent stage is the most pivotal in
clinical learning because the learner must begin
to recognize patterns and determine which
elements of the situation warrant attention and
which can be ignored.
 The competent nurse devises new rules and
reasoning procedures for a plan while applying
learned rules for action based on the relevant
facts of that situation.
 Knows what to prioritize first; looks for smaller
pic or “symptoms”
4. PROFICIENT
 The performer perceives the information as a
whole (total picture) rather than in terms of
aspects and performance.
 Proficient level is a qualitative leap beyond the
competent.
 Nurses at this level demonstrate a new ability to
see changing relevance in a situation including
the recognition and the implementation of
skilled responses to the situation as is it evolves.
 Pwede na iwan ng doctor; looks for bigger pic or
lahat ng signs and symptoms
5. EXPERT
 The expert performer no longer relies on an
analytic principle (rule, guideline, maxim) to
connect her or his understanding of the
situation to an appropriate action.
 The expert nurse, with an enormous background of
experience, now has an intuitive grasp of each
situation and zeroes in on the accurate region of the
problem without wasteful consideration
 Pwede maging N ang E pag lumipat ng
area/specialty
4 METAPARADIGMS
NURSING
 described as a caring relationship, an “enabling
condition of connection and concern”
 “Nursing is viewed as a caring practice whose
science is guided by the moral art and ethics of
care and responsibility”
 “Caring is primary because caring sets up the
possibility of giving help and receiving help”
PERSON
 The person is a self-interpreting being, that is
the person does not come into the world
predefined but gets defined in the course of
living a life.” - Dr. Benner
 Four major aspects of understanding that the
person must deal with:
1. the role of the situation
2. “” the body
3. “” personal concerns
4. “” temporality
 Predefined life will always be; di naniniwala sa fake
SITUATION
 To be situated implies that one has a past,
present, and future and that all of these
aspects… influence the current situation.” - Dr.
Benner
 because situation conveys a social environment
with social definition
 don’t judge a person kung di mo pa nae-
experience ang situation niya
HEALTH
 “on the lived experience of being healthy and
being ill”
 Health is defined as what can be assessed,
whereas well-being is the human experience of
health or wholeness.
  Health is not just the absence of disease and LOGICAL FORM
illness.  QUALITATIVE DESCRIPTIVE RESEARCH - Dreyfus
 Disease – lagnat, symptomatic, nakikita, empiricism Model of Skill Acquisition to better understand
 Illness – dysfunction or experience of loss; mentally skill acquisition in clinical nursing practice
broken & no symptoms (distinguishing N to E)
MAJOR CONCEPTS
THEORY OF CARITATIVE CARING
1. ASPECTS OF A SITUATION
KATIE ERIKSSON
 situational components that are understood
 November 18, 1943 born in Jakobstad, Finland
due to the nurse's previous experience
MAJOR ASSUMPTIONS
2. ATTRIBUTES OF A SITUATION
1. AXIOMS - fundamental truths in relation to the
 Situation that can be explained w/o having an
conception of the world; belief; self
experience in the situation
2. THESES - fundamental statements concerning the
3. COMPETENCY general nature of caring science; scientific;
 is “an interpretatively defined area of skilled Proven; experimental
performance identified and described by its
AXIOMS
intent, functions and meanings"
 The human being is fundamentally an entity of
4. DOMAIN body, soul, and spirit.
 area of practice that has several competencies  “ ” a religious being.
with similar intents, functions and meanings  “ ” holy. Human dignity means accepting the
5. 6EXEMPLAR human obligation of serving with love, of
 an example of a clinical situation that conveys 1 existing for the sake of others.
or more intents, meaning, fx or outcomes easily  Communion is the basis for all humanity. Human
translated to other clinical situations beings are fundamentally interrelated to an abstract
and/or concrete other in a communion.
6. EXPERIENCE
 Caring is something human by nature, a call to
 an active process of refining and changing
serve in love.
preconceived theories, notions and ideas when
 Suffering is an inseparable part of life. Suffering
confronted with actual situations
and health are each other’s prerequisites.
7. MAXIM
 Health is more than the absence of illness.
 is a cryptic description of skilled performance
 Health implies wholeness and holiness.
that requires a certain level of experience to
recognize the implications of the instructions  The human being lives in a reality that is
8. PARADIGM CASE characterized by mystery, infinity, and eternity.
THESES
 creates new clinical understanding and opens
 Ethos confers ultimate meaning on the caring context.
new clinical perspectives and alternatives
 The basic motive of caring is the caritas motive.
9. SALIENCE
 The basic category of caring is suffering.
 choosing which is more important on the
 Caring communion forms the context of
present aspects of the situation
meaning of caring and derives its origin from
10. 1ETHICAL COMPORTMENT
the ethos of love, responsibility, and sacrifice,
 "Clinical and ethical judgements are inseparable
namely, caritative ethics.
and must be guided by being with and
 Health means a movement in becoming, being and
understanding the human concerns and doing while striving for wholeness and holiness,
possibilities in concrete situations" (Benner, which is compatible with endurable suffering.
2000)  Caring implies alleviation of suffering in charity
11. HERMENEUTICS love, faith and hope. Natural basic caring is
 Describing and studying a meaningful human expressed through tending, playing and learning
phenomenon in a careful and detailed manner in sustained caring relationship, which is
based on practical understanding asymmetrical by nature.
 “knowing how” one could gain knowledge & skills
 “Knowing that “ w/o even learning the theory
4 METAPARADIGMS
NURSING
 Caritative Care Ethics makes a basic distinction
between:
 Caring Ethics - core of nursing ethics, deals
with patient-nurse relationship.
 Nursing Ethics – deals with ethical
principles and rules that guide nursing
decisions.
 Love and charity, or caritas, as the basic motive of
caring
 Ethics – guided by law
HUMAN BEING
 based on the axiom that the human being is an
entity of body, soul, and spirit; a religious being
 The patient is a suffering human being or a
human being who suffers and patiently
endures.
ENVIRONMENT
 Characteristics the total caring reality based on
cultural.
 Preserving respect, dignity and holiness of the
human being.
HEALTH
 Health as soundness, freshness, and well-being.
 Health is conceived as a becoming, a movement
toward a deeper wholeness and holiness.
 a movement occurs that becomes visible in the
different dimensions of health as doing, being,
and becoming with a wholeness that is unique
to human beings.
MAJOR CONCEPTS
1. CARITAS
 Caritas means love and charity
 fundamental motive of caring science, also
constitutes the motive for all caring.
 It means that caring is an endeavor to mediate
faith, hope, and love through tending, playing,
and learning.
2. CARING COMMUNION
 constitutes the context of the meaning of caring and
is the structure that determines caring reality
 source of strength and meaning in caring.
 Form of intimate connection that characterizes caring
 characterized by intensity and vitality, and by
warmth, closeness, rest, respect, honesty and
tolerance.
3. THE ACT OF CARING
 contains the caring elements; faith, hope, love,
tending, playing, and learning
 Art of making something very special out of
something less special.
4. CARITATIVE CARING ETHICS
 deals with the basic relation between the
patient and the nurse-the way in which the
nurse meets the patient in an ethical sense.it is
about the approach we have toward the
patient.
5. DIGNITY
 Human dignity is partly absolute dignity, partly
relative dignity. Absolute dignity is the granted
human being through creation while relative
dignity is influenced culture and formed
through culture and external contexts.
6. INVITATION
 refers to the act that occurs when the career
welcomes the patients to the caring
communion.
 concept of invitation finds room for a place
where the human being is allowed to rest, a
place that breathes genuine hospitality
7. SUFFERING
 is an ontological concept described as a human
being's struggle between good and evil in a
state of becoming
 is a unique, isolated total experience and is not
synonymous with pain
8. SUFFERING RELATED TO ILLNESS, TO CARE, AND
TO LIFE
a) Suffering related to illness - experienced
in connection with illness and treatment
b) Suffering related to care when the
patient is exposed to suffering caused by
care or absence of caring
c) Suffering related to life the situation of
being a patient, the entire life of a human
9. THE SUFFERING OF HUMAN BEING
 is a suffering human being or a human being
who suffers and patiently endures
10. RECONCILIATION
 refers of the drama of suffering
11. CARING CULTURE
 is the concept that Eriksson uses instead of
environment. It characterizes the total caring
reality and is based on cultural elements such as
traditions, rituals and basic values.
THEORETICAL ASSERTIONS
FOUR LEVELS OF KNOWLEDGE
1. the meta-theoretical
2. the theoretical
3. the technological
4. caring as art
LOGICAL FORM
 hypothetical deductive method and
hermeneutics guiding principles.
UNITARY HUMAN BEING
Martha Elizabeth Rogers
 May 12, 1914 born in Dallas,Texas USA
 Professor Emerita
 March 13, 1994 died at 79 years of age.
4 BLDG. BLOCKS
ENERGY FIELD
 Fundamental unit of both the living & non-living
 Field is a unifying concept, and energy signifies
the dynamic nature of the field. Two fields are
identified: the human field and the
environmental field.
 Infinite and pandimensional.
 Unitary human being (human field) is defined as
an irreducible, indivisible, pandimensional
energy field identified by pattern and
manifesting characteristics that are specific to
the whole and that cannot be predicted from
knowledge of the parts.
 Environmental field is defined as an irreducible,
pandimensional energy field identified by
pattern and integral with the human field.
UNIVERSE OF OPEN SYSTEMS
 Hold that energy field are infinite, open and
integral with one number.
 Human and environmental fields are in
continuous process and are open systems.
PATTERN
 Identifies energy field.
 Nature of the pattern changes continuously and
innovatively and these changes give identity to
the energy field.
 Is an abstraction; it reveals itself through
manifestation.
 Wholeness; may sinusunod; may routine
 ‘pag nawala ang pattern, may mangyayari sayo
(changes); ADL’s ; rounds
 Focus on whole rather than specific
 Change in environment; magkakasakit
PANDIMENSIONALITY
 Rogers defines pandimensionality as a nonlinear
domain wthiout spatial or temporal attributes
 The term pandimensional provides for an
infinite domain without limit.
 Circular or non-limit
 Time is linear for Japanese, di na pwede maibalik.
Time is limitless for Filipinos (procrastinating)
4 METAPARADIGMS
NURSING
 Learned profession and is both a science and an art.
 Rogerian nursing focuses on concern with
people and the world in which they live—a
natural fit for nursing care, as it encompasses
people and their environments.
 Interaction of person & envi to max health potential
 Science kung anong ginagawa at ina-apply. Art
or creativity kung paano ginagawa
PERSON
 Rogers defines person as an open system in
continuous process with the open system that is
the environment (integrality).
 She defines unitary human being as an
“irreducible, indivisible, pandimensional energy
field identified by pattern and manifesting
characteristics that are specific to the whole”
HEALTH
 She uses the term passive health to symbolize
wellness and the absence of disease and major
illness.
 Wellness “is a much better term because the
term health is very ambiguous”
ENVIRONMENT
 “an irreducible, pandimensional energy field
identified by pattern and manifesting
characteristics different from those of the parts.
 Each environmental field is specific to its given
human field. Both change continuously and
creatively.
 Environmental fields are infinite, and change is
continuously innovative, unpredictable, and
characterized by increasing diversity.
 Nararamdaman pero hindi nakikita
THEORETICAL SOURCES
 Rogerian’s science emerged from the
knowledge bases of anthropology, psychology,
biology, physics, math and literature.
 Nightingale’s proposal and statistical
 THEORETICAL ASSERTION – MARTHA ROGERS
Evolution of Principles of Homeodynamics: 1970, 1983, 1986, and 1992
PRINCIPLES OF An Introduction to Nursing: A Science of Dimensions of Nursing
HEMEODYNAMICS the Theoretical Basis Science of Unitary Human Health: A View Science and
of Nursing, 1970 Unitary Man, Beings: A From Space, the Space
1980 Paradigm for 198 Age, 1992
Nursing, 1983
Continuously
propagating series of Continuous change from lower- to higher frequency wave patterns in the
RESONANCY waves bet. man and human & environmental fields
environment
HELICY Continuous, Nature of change Continuous Continuous, Continuous,
innovative change bet human & innovative, innovative, innovative,
growing out of mutual envi’al fields is probabilistic, probabilistic, unpredictable,
interaction of man & continuously increasing increasing, and increasing
innovative,
envi along a spiraling diversity of environmental diversity of
probabilistic, &
longitudinal axis increasingly
human & envi’al diversity human and
bound in space-time diverse, field patterns, characterized environmental
manifesting characterized by by field patterns
nonrepeating nonrepeating nonrepeating
rhythmicities rhythmicities rhythmicities
RECIPROCY Continuous mutual
interaction the human -------------------------------------------------------------------------
& envi’al fields
SYNCHRONY Change in the human Continuous,
field & simultaneous mutual,
state of envi’al field simultaneous Continuous, mutual human field and environmental
at any given point in interaction field process
space-time between human
&
environmental
fields

PRINCIPLES OF CHANGE
HELICY
 Evolution
 describes spiral development in continuous, nonrepeating, and innovative patterning.
 describing the nature of change evolved from probabilistic to unpredictable, while remaining continuous and
innovative.
RESONANCY
 intensity of change
 patterning changes w/ the dev’t from lower to higher frequency w/ varying degrees of intensity
 Resonancy embodies wave frequency and energy field pattern evolution
INTEGRALITY
 wholeness
 stresses the continuous mutual process of person and environment.
 The principles of homeodynamics (nature, process, and context of change) support and exemplify the assertion
that “the universe is energy that is always becoming more diverse through changing, continuous wave
frequencies
LOGICAL FORM
 DEDUCTIVE AND LOGICAL - the theory of relativity, the general system theory, the electrodynamic theory of life,
and many other theories contributed ideas for Rogers’ model