Preface This book is based on a dialogue with nurses and nursing, descriptive research that identified five levels of competency in clinical nursing practice. These levels -- novice, advanced beginner, competent, proficient, and expert -- are described in the words of nurses who were interviewed and observed either individually or in small groups. Only patient care situations where the nurse made a positive difference in the patient's outcome are included. These situations offer vivid examples of excellence in actual nursing practice. They are not abstract ideals, however; they emerge from the imperfections and contingencies with which nurses work daily. A Note to the Skeptics Some who read the exemplars will be skeptical that such nursing is possible. Their skepticism is warranted, because these examples are drawn from outstanding clinical situations where the nurse learned something about her practice or made a significant contribution to a patient's welfare. But if the reader's skepticism stems from a generalized disillusionment with nursing in hospitals and from the belief that nurses are rendered impotent to give compassionate, lifesaving care in hospitals -- then this book offers a resounding rebuttal to the skeptic and a ray of hope to the disillusioned. The Perceptual Origins of Excellence This book questions some of nursing's most dearly held beliefs and assumptions. The book asserts that perceptual awareness is central to good nursing judgment and that this begins with vague hunches and global assessments that initially bypass critical analysis; conceptual clarity follows more often than it precedes. Experienced nurses often describe their perceptual abilities using phrases such as "gut feeling," a "sense of uneasiness," or a "feeling that things are not quite right." This kind of talk makes educators and clinicians uncomfortable, because the assessment must move from these perceptual beginnings to conclusive evidence. Expert nurses know that in all cases definitive evaluation of a patient's condition requires more than vague hunches, but through experience they have learned to allow their perceptions to lead to confirming evidence. In the quest for a scientific rationale, the importance of perceptual skills can be overlooked by any clinician -- nurse, physician, or counselor. If nurses were disembodied computers or mechanical monitoring devices, they would have to wait for clear, explicit signals before identifying one singular feature of a problem. Fortunately, however, expert human decision makers can get a gestalt of the situation and proceed to follow up on vague, subtle changes in the patient's condition with a confirmatory search aided by the whole health care team. Experts dare not stop with vague hunches, but neither do they dare to ignore those hunches that could lead to early identification of problems and the search for confirming evidence. The Importance of Discretionary Judgment Considering the early history of nursing education in this country, I am concerned that the model of skill acquisition described here could be misinterpreted as advocating informal trial-and-error learning. Therefore, it is important to point out that the Dreyfus Model of Skill Acquisition was originally developed in research designed to study pilots' performance in emergency situations. In that context, no one worried that people might misinterpret the model and suggest that the pilot should just go out and "get the feel of the plane" through trial and error; under those circumstances the beginning pilot would not even survive basic training. The same holds true for nursing. Providing nursing care involves risks for both nurse and patient, and skilled nursing requires well-planned educational programs. Experience-based skill acquisition is safer and quicker when it rests upon a sound educational base. This book's purpose is toPatricia Benner is the author of 'From Novice to Expert: Excellence and Power in Clinical Nursing Practice, Commemorative Edition', published 2000 under ISBN 9780130325228 and ISBN 0130325228.