the nurse theorists portraits of Excellence Volume 2 in this Edition we feature Dr Patricia Benner I was born in August 1942 in Hampton Virginia just after the United States entered World War II my parents Shirley and Clint Sawyer had moved from North Carolina to Virginia in order for my father to work in the shipyard building ships my sister Luanne was 2 and 1/2 years old when I was born she is an influential older sister who was my most constant Playmate in childhood and my very close adult friend my youngest sister June completed our family when she was born in January 1952 the three of us are very close and supportive of one another even though we have always lived in different states we we moved to Ontario California not far from Pomona where both my older sister and I went to chaffy Union High School my parents divorced when I was a sophomore in high school this was a very difficult time in my life but I had wonderful friends in high school many of whom are still friends today I took a college preparatory course and because of the first Russian satellite sputnic I took physics in addition to chemistry I went to Pasadena College of private liberal arts college where I majored in Theology and science at the time I planned to do medical missionary work I was most interested in laboratory Sciences but was also interested in nursing after I worked in the admitting office of St Luke's Hospital in Pasadena while in college my college did not have a nursing school at time so I went to Pasadena City College and an associate degree nursing program in addition to simultaneously continuing with my Balor program this last two years of college I went to the Nazarene Theological Seminary where I studied two years with a very influential Professor Dr Paul orala a psycholinguist a cultural Anthropologist Minister musician and well-known missionary to Haiti he was a dynamic teacher and I was able immediately to use his anthropological insights and skills to create changes in the emergency department and then in one of the first coronary care units in the county at Kansas City General Hospital I met Richard Benner in 1966 and we married in August 1967 we immediately moved to Stanford University my husband has been a constant colleague debate partner and intellectual soulmate since I met him in Kansas City we have influenced each other's work but Richard's award-winning dissertation on a situational and interpretive model of leadership had a profound influence on my understanding of practice and on all of my intellectual projects I worked as a visiting nurse in San Jose area and then at Stanford University Hospital Intensive Care Unit I then entered the master's program in nursing at the University of California San Francisco in September 1969 and graduated in June 1970 you UC CSF was a wonderful opening of new studies and understandings for me I remember that my mother was very surprised when I wore a black armband to protest the Vietnam War at my graduation influential were the teachings of Dr Jee Quint benol on end of Life Care Dr Shirley Chader Dr Reber chier in education Dr June Bailey in education and also Dr Marlene Kramer and Dr Helen nom who was the dean of UCSF at the time I went to work for Dr Marlin Kramer as an associate research nurse specialist in September of 1970 our son John was born in December of 1973 and 8 years later our daughter Lindsay Caroline was born in 1981 when our son was just 2 years old I entered the doctoral program at University of California Berkeley as a non-divisional student in the school of education I studied with Dr Richard Lazarus who was in the edsy department and joined his Dynamic research team the Berkeley stress and coping project in order to study stress and coping in a healthy middle-aged Community sample I co-authored two papers with Dr uh Richard Lazarus and I work closely with brilliant doctoral student colleagues including Dr Judith rubel Dr Susan and folkman and others in the Berkeley stress and coping project who really continue to be colleagues today Dr Judith Rubble has particularly been a close friend colleague and one with whom I have shared the hopes dreams and challenges of being mothers to our children two years into my doctoral studies I consulted with Dr Lazarus about taking a mindbody philosophy course to further our account of mindbody relationships this was a turning point in my my intellectual development I took a course on kirkgard taught by Dr Hubert dfus and his research assistant Jane Rubin now Dr Jane Rubin I also took courses from Dr dfus on Marlo ponti a French thinker who advanced theory on the social sentient body and on the interpretive phenomenology of Martin heiger haider's writing and thinking were extensively influenced by kard and it was kard ards Notions of the relationally meaningful constituted relationships between mind and body that influenced my work during my doctoral studies Dr Charles Taylor a longtime friend of Dr Hubert dfus came to Berkeley to give lectures in classes three times and his thinking became influential also this was a very exciting time in the development of the human Sciences Michelle Fuko came to Berkeley to meet and engage in dialogue about his philosophy and methods in the human Sciences at this time I graduated from UC Berkeley in June 1982 and began my work as an associate professor at UCSF at the end of June 1982 from novice to expert excellence and Power in clinical nursing practice was published in 1984 within the same thought project in co-authorship with my doctoral colleague Dr Judith rubel Judith and I worked on and developed a reinterpretation of the Lazarus cognitive phenomenological transactional theory of stress and coping in a book entitled The Primacy of caring stress and coping in health and illness that was then published in 1989 from novice to expert and the Primacy of caring we received American Journal of Nursing book of the Year award these two books along with my edited book interpretive phenomenology present a rather full picture of my articulation of nursing knowledge skill intense and practice from an interpretive phenomenological perspective my colleagues Dr Christine Tanner and Dr Katherine chesla and I were funded by the fold Foundation to study skill acquisition of new graduate nurses this study was a continuation and extension of the earlier work from novice to expert we published our findings in the book expertise in nursing practice caring ethics and clinical judgment in 1996 the next study clinical wisdom and interventions in critical care with my colleagues Dr Patricia Hooper kitis and Dr Daphne Stannard focused on advanced practice nurses as well as the original full sample of expert nurses to articulate the nature of clinical wisdom embedded in the practice of nurses in critical care units in transport care and in the emergency department my current research under the offices of the Carnegie foundation for the advancement of teaching is a national study on the education of undergraduate nurses my colleagues in this study are Dr Molly suan Dr Victoria Leonard Khan Dr Lisa day and support and consultation with uh senior Carnegie Scholars Dr William Sullivan and Dr an Colby along with the wonderful guidance from Dr Lee Schulman president of the Carnegie foundation for the advancement of teaching this work will be published early in 2009 by Carnegie foundation for the advancement of teaching and josi bass [Music] Publishers Dr Martha Riley Alig good met with Dr Patricia Benner on University of California's San Francisco campus Patricia I'm so pleased to be here with you today in San Francisco and to talk with you about your exciting work that you've accomplished over these years and I know the viewers are going to be so pleased to hear about your work and to hear it in your own words well you're so welcome uh here at the University of California in San Francisco and in fact we're in um the anel Strauss uh room uh out of the uh Department of Social Behavioral Sciences so welcome uh to the school and to the department Patricia I'd like for us to begin uh by talking about how your theoretical work all began and maybe you could share with the viewers about that and I think they'd be interested in if there were people particular people who had an influence in that beginning work well I think I was really strongly influenced by my learning from patients and from my experience as a as a nurse um but then when I was in my graduate school at UC Berkeley I worked with Richard Lazarus in the stress and coping project and in the process of that wonderful study we were studying um people in the community rather than um people who were ill and we were studying um hundred people who were middle-aged and a bit older and we were interested in how they coped with the everyday stresses of life and so so that fit perfectly with uh the things that I was interested in and of course people would even be ill during the year um as we studied them and I asked dick Lazarus who became a very good friend and was a wonderful Mentor if I shouldn't go over to the philosophy department and take a mindbody philosoph uh philosophy class and we were doing all kinds of transitions at the time transitioning Dick's research from the laboratory to the community and we were trying to develop this notion of a transactional view of stress so that it was really a view of the person both uh setting up and constituting the situation and being constituted by that situation so it was neither the person nor the environment alone but the two in interaction so I just with very um dumb luck uh stumbled into uh Hubert daus's course on kard because of course kard was a really wonderful mindbody philosopher and it was lifechanging for me I suddenly had a new language to talk about the person in the situation about um relationships self-defining relationships and concerns and I also got a real sense of how we are known and come to know ourselves in relationship and in dialogue um um so I um through studying kard I ended up going back and taking the kard class another five times but it was changing each time the interpretation was growing and uh I was so fortunate to um have the mentorship of Dr Bert dfus and um uh Jane Rubin who was his teaching assistant and I went on from th those that initial series of care classes to study Mero ponti as taught by uh Hubert dfus and Maro panti is one of our I think the foremost uh philosophers and theorists on mindbody relationships and also the courses on heiger which were a wonderful deconstruction of the cartisian view of the private subject standing over against and apart from an objective world so this was all language that I needed to uh to describe what's going on in these intimate uh caregiving relationships between nurses and patients and over the years um really almost 30 years uh I've had students go back and take uh Bert dfas's courses he's still teaching and uh each time the students um some 48 of them have said well I needed this language I I this was something that was really useful to me and helped me articulate what I know and practice and I I find it very reassuring that my experience was replicated by those students they didn't feel like I had shoved them into a class that was difficult that they didn't want to take it was really uh very useful and the students found it useful in some of the same ways and even different ways than I found it useful um I also felt really fortunate in my teaching in that my students could always take the philosophy for firsthand from a really world-renowned philosopher and um even his colleagues because Charles Taylor his very close friend came and taught at least two different years while I was at Berkeley and I took courses from him on interpretation and the Sciences of man or persons and um I really uh appreciate the fact that all of my students could follow and take coursework in the philosophy Department dep and then I would spend a great deal of time um mentoring with them on how we understood this in relation to nursing I'm sure over the years that people come up and talk to you at conferences and so forth about your theory and your work and I wonder if you've come up with a brief description uh that you might share with the viewers today well I wish I had a really a quick short poetic answer to that because but of course because I'm working in a philosophical tradition my only innovation has been to take that into nursing and see what it sounds like looks like uh feels like from a nursing perspective and from the patients perspective of experiencing illness recovery learning to cope and manage multiple chronic illnesses so with that caveat I the this uh philosophical approach has given me a way to study um skill acquisition or coping at the very high end and uh skills and coping uh in the midst of um uh illness and suffering and uh struggle so uh I'm always interested in studying the person in the situation and the focus of the work is really on articulating the knowledge that's embedded in um everyday practice uh whether it be nursing practice mothering practices um fathering Parenthood practices or uh ethical comportment uh ethical relationships uh clinical imagination uh clinical knowledge skills and habits and development so I'm always very interested in um practical knowledge practical wisdom embedded in everyday life and this view of practice is actually part of the theory and that is to view practice as a way of knowing in its own right uh not that it's infallible not that it doesn't need to be augmented or enriched by Theory but I think um practice is a larger house than Theory or science and uh we need to study what we've learned experientially in practice in order to guide the science and the technology which are located in the house of practice so I don't have any sort of oppositional View of theory and practice rather that the two are in dialogue with one another and um that isn't very succinct and I apologize for that well now the but the focus is it's really focus on habit skill knowledge embedded in practice um relationship relational understanding self- understanding identity uh ethical comportment formation uh coping with illness all of these things that are located in our everyday life worlds as compared to a more detached uh view of the looking on the person uh outside the situation I'm my starting point is always looking at the person studying the person in context in the situation and my view of knowledge within a practice is always that of situated knowledge okay next I'd like for us to talk about your theory with regard to education practice and research and I'd also be interested in whether any one of those is more important in your mind uh than another well they all they all um are important and um I I have been so um pleased and benefited from working with many wonderful colleagues um and doing research in this tradition ition um this interpretive phenomenological position and so uh I've worked with over 48 doctoral students for example and many post-doctoral students and my um colleagues also here at UCSF um and I can now really say that the research tradition in this um in interpretive phenomenology is really grown um there are many studies now about stress and coping with illness about ethical comportment about um ethical concerns um uh for example Lisa day did a study of uh the role of etiquette in ethical comportment in transplantation uh so it's really opened up new ways of understanding many areas of nursing practice and many issues that uh patients and families face there have been uh thanks to the work of kit Tesla and Vicky Leonard Khan and Lee Smith battle there have been many studies on families um uh Lee Smith has studied uh uh teenage mothers uh and has actually from her dissertation followed these mothers for 16 years so and there are many um many studies internationally and nationally um so I think the research tradition has grown really well and um uh currently uh I'm collaborating with my husband and the federal nurses group in um army navy and Air Force to study uh experiential knowledge gained in Afghanistan and uh Iraq uh because the healthc care delivery has changed phenomenally in this particular uh war and um so we're studying uh what the nurses have learn learned in the front line with this uh change in the healthcare delivery there so when you think of these areas would you say that one of those is more important than the other I think practice is probably uh the highest impact area because um many many hospitals I've lost track of the number have used uh for example the novice expert in the clinical wisdom and the expertise in nursing book to um develop uh clinical promotion programs and even better to develop uh projects of articulating knowledge embedded in their most expert practice or in Breakdown situations they've also um used the novice expert as as a a a way to think about orienting new nurses and for mentoring them across the stages of skill acquisition um so accrediting bodies have used it um and um in Australia they they do things in a very uh big organized ways and so whole uh provinces have used it as a way of um granting clinical promotions I'm very pleased with the fact that we now have many many clinical promotion programs and so the only way to advance in practice salary-wise is no longer to uh go into uh Administration or um and of course now nurse Educators don't make as much as clinicians so maybe that's a little bit of problem but uh I think it has had an impact on uh the growth of practice knowledge and paying attention to what nurses know in their practice and education uh a number of schools have used uh particularly Primacy of caring as a um a curricular integration tool and um I I was pleased at Harvard the they they used um I don't know if they still do but they used at one time Primacy of caring in the Harvard Medical School and also at UCLA um so um these you know there there has been um an impact on education but currently I'm involved in a national study conducted by the Carnegie foundation for advancement and teaching and we are examining uh Nur undergraduate Nursing education and um and of course I bring with me some of my perspectives into that study but we've done a really open-ended qualitative study of um Nursing education practices um you might be interested to know that one of the in each of these that Carnegie has done a series of studies of professions Engineers clergy law medicine and nursing and the sort of ethical Division behind all of this is to come up with uh a broader uh uh Civic professionalism rather than the narrow um sort of talot Parson um model of narrow rational technicality and um so we've had the opportunity to do dialogue with the other professions as we've uh studied Nursing education so I think um um in terms of pedagogies I think um you you might be interested to know that the pedagogy most um common in nursing education is that of really situated coaching which makes total sense to me because practice is always situated action and and and knowledge and skill and um nurse Educators typically are excellent coaches in the clinical situation and um so I think this work might have more influence on education as time goes by but that would I would say that's the least point of influence at this point Patricia I'm sure that many contributions have been made to nursing knowledge through your work uh but would you discuss that a little little bit yourself what contribution do you see and do you consider this theoretical work your your major contribution well um I think I've never done anything more significant than my actual nursing practice in care of patients I think that's uh amazingly complex and compelling compelling work I have drawn all of my theoretical ins insights or my articulation it's really a better way of putting it insights directly from the practice of expert nurses I do think that introduction of the use of narrative as a way of capturing historical clinical reasoning and as a way of capturing the perception of nurses has made a real contribution in clinical knowledge development in practice um we've done and this I say we with my husband have done um a large number of projects with hospitals uh Massachusetts General Beth Israel in Boston uh Children's Hospital at Yale of going in and helping nurses write firstperson experience near narratives and the thing about this is not a deficit approach you can give a nor is it a heroic approach um you can give a clinical situation where everything went wrong it was real breakdown and and in studying that narrative you can see what were the failed uh areas of practice what were the failed Notions of good and here I'm not talking about personal failures I'm just saying how it didn't come together and um you can ALS you also learned a tremendous amount from asking nurses to write clinical narratives about uh a situation where they learn something new or a situation that they thought was really the quintessence of their practice and then we really really pour over those narratives and don't exit them into stages of skill acquisition or anything else but rather look at the Notions of good that were embedded in the narrative the areas of knowledge and skill and all the in order to and for sake of the significance of that nursing care and begin to really give public language to that so that you can take the experiential learning of uh a nurse and make it accessible and therefore make it more uh Collective and cumulative so it can grow over time and that's been a very satisfying area of work in nursing practice for me is really introducing the way narrative can help people and and there's a particular way that narrative is used and that's the that the the only instruction ever is first person this comes from Clifford ge's work in anthropology but it's a first person experienc near account of a clinical situation and I prefer it orally rather than written although I have had people write them but oral uh telling is better because it could be more circular oh I forgot to tell you this oh besides this other thing was going on and so you get more of the information about the context and perception and um it is possible to identify uh the knowledge and skill areas that the nurse is struggling with the Notions of good they're struggling with in their practice in this practice situation Patricia is there a particular narrative that would illustrate what you're describing yes I'm thinking of this one story that still grips me um and this ICU nurse was working with a patient older man whose father was a physician and the patient came in and the son was who was a physician demanding everything be done and so there were like millions and millions I'm exaggerating orders all at once and um he was in terrible uh respiratory distress and so she was starting uh and the blood pressure vital signs were not good he was very unstable so she was starting all the drips she was uh assisting with the intubation and getting uh helping with the respiration and um but meanwhile this man is in horrible pain and she's so caught up and um she couldn't get the team uh the resident team was in there but she couldn't get any of them to attend to the pain management at the time so she really needed an attendant or someone more experienced and she tells this story she was at least comforting him but she felt so sad that that she didn't call in her nursing colleagues hindsight you know it's always 2020 um that she didn't call for help and that she didn't uh effectively convey and she said but you know I learned a lot out of this next time I will call my nursing colleagues in and I'll get them to take my place and I'll go talk to the attending because I have a better firsthand grasp of the situation so I I love those kinds of narratives where you're really learning a lot from the situation because as we all know those um clinical situations are very complex fast moving and underdetermined uh we um live them forward we understand them backward quite often um so I that that story stands out for me some people think that we're we're only looking at heroic stories and if you really read um if you really read the stories that are in clinical wisdom or expertise and nursing practice or novice expert they really aren't heroic stories they're situated stories of um knowledge and skill and relationship but they may be uh accounts of situations when everything went wrong um and and that's the other lovely thing about narratives is that you can talk what was talk about what was possible given the fact that there was only one LVN on the floor with you at the time or there was you know uh The Physician had gone out for a jog and had his earphon Zone and you couldn't reach him or whatever these wild and bizarre circumstances are you can include it in the narrative and um so one of the rules of interpreting narratives is you know not to fold your arms and say well what if you had done but rather um look squarely at the limitations and the boundedness of that situation and what were the resources constraints and limitations of the situated of situation because our our work is always situated like that in very complex underdetermined uh clinical situations so then the work that you did originally for novice to expert forms a basis for all this other work it does but it's in concert with um that work on stress and coping and the Primacy of caring um to understand the nature of the life world and the lived experience and and not always split the person off from from that to keep the person in the situation whether you're studying coping or knowledge and skill embedded in practice or whatever you're studying is keep that together and keep that embedded and you wanted to know um what you think what influence my work has had uh or what do I think is my major contribution I I I think it might be too soon to tell that I don't really know um uh but I think that uh this work is given language for uh nurses as knowledge workers and a new level of understanding of the nature of practice itself that practice isn't a mere sort of technical stamping out of a theory but rather uh a dialogical relationship with Theory and um an Ara Ena where new knowledge is developed every day experientially and it's also an area where there's a lot of local specific clinical knowledge that we need to capture and articulate in order to make our clinical science grow well that's really interesting thank you it's been wonderful being here and talking with you today as we close this interview I wonder if there's anything else you'd like to share with the viewers thank you very very much and I I I suppose it would be appropriate to con close by saying that um every nurse in practice has an incredible vantage point on the human condition on uh the value of uh connection and care and uh is in a great position to articulate what they learn experientially from their practice it's been wonderful being here with you today and talking with you visiting with you you uh but hearing about your work and hearing it from you has been very special for me and I know it will be for our viewers I want to thank you Patricia for agreeing to do this interview well it's been my pleasure I've enjoyed the discussion my 48 doctoral students at UCSF and 20 dissertation advises from other universities and many post-doctoral students and international Scholars have also advised IED me well and taught me much they have profoundly influenced the development of this work and extended it in many new directions I believe that it is now a growing tradition and is influencing practice and [Music] education [Music]