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The Language of Caring

Monday July 10, 2000
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Patricia Benner, RN, PhD, FAAN, may live in California, but her nursing spirit roams freely somewhere between science and philosophy.
Benner, a professor of nursing at University of California-San Francisco, has devoted most of her career to articulating the language of caring and excellent practice. Influenced by University of California-Berkeley philosopher, Hubert L. Dreyfus, Benner gives voice to the clinical wisdom demonstrated by expert nurses.
Her most recent book, coauthored by Patricia Hooper-Kyriakidis, PhD, RN, and Daphne Stannard, PhD, RN, is entitled Clinical Wisdom and Interventions in Critical Care: A Thinking-In-Action Approach.1 The book is based on data collected for Benner's previously published book,2 as well as hundreds of additional interviews with nurses in critical care.
"In all of my work, the notion of what it is to have a practice is a key, fundamental emphasis," says Benner. "I'm always using philosophical strategies to articulate, to give language to knowledge that is embedded in the practice. I'm never studying individual practitioners, but rather what I can collectively learn from practitioners in practice."
Benner found in prior research that many nurses are unable to articulate how they know to make certain decisions about their patients. Instead these nurses imagine that making a clinical judgment is merely weighing one objective choice against another. This conclusion, coupled with the rapid knowledge development in the critical care nursing field, led the authors to write the book.
"The knowledge development that has gone on in caring for critically ill patients really spurred us on," says Benner. "We also wanted to develop a work that nurses who were beginning their practice in critical care could use as scaffolding to get a vision of the nature and logic of critical care nursing practice."
According to Benner, it's a time in both medicine and nursing when we want to put everything in "formalizable" terms and guide practice with clinical pathways and algorithms. "But that is never enough because these pathways never capture the thinking about a particular patient across time," she says. "However, taken together, I believe my work discloses much about the nature of clinical thinking which, though it uses science, is quite different from scientific thinking and scientific problem solving. Clinical thinking is always thinking about 'the particular' across time, keeping track of the changes as they evolve, and keeping track of the clinician's understanding of the changes."
In observing the comforting practices in critical care, Benner found that without a well-developed sense of providing comfort, nurses were unable to make good clinical decisions. "If you don't have very rich, comforting practices for these critically ill patients, you can't make good clinical judgments about the technological interventions," she says. "You lose your way in the technology if you haven't attended to the body's recuperative powers and comfort." This concept is in opposition to the school of thought that one needs to take care of the technology before taking the time to comfort the patient.
Benner adds, "Sometimes people think that the psychosocial and comforting aspects are less important in critical care because you're busy saving lives. In fact, it's even more critical when patients are critically ill that the ordinary comfort measures are done well."
In this era of managerialism, Benner struggles against the loss of our practice as nurses. "As clinicians, we never perform in isolation. Our practice is embedded in a team or community of clinicians or practitioners. Practitioners, both individually and collectively, must look patients in the face, bear witness to the illness experience, and form relationships. Without this practice tradition, the healthcare system becomes frankly dangerous."
One of the major domains of nursing practice made clear by Benner in an earlier work3 was that of teaching/coaching. Although healthcare systems are terribly destabilized and fragmented, Benner insists that nurses resist losing the teaching function of their practice even when the current environment doesn't make space for it. "Caring practices are at risk for being marginalized and not being considered in organizational structures. Losing such a vital and lifesaving domain in nursing is like a theft. We can't allow it to happen."
Benner asserts that one of the main reasons many patients are admitted to the hospital is that there has been a breakdown in everyday care structures. The patients are then given medical diagnoses when, in reality, their care could be restructured within the home and community setting.
She uses the example of the home care nurse who worked with a woman with Type I diabetes to cut down on frequent hospitalizations by using many different nursing interventions, not the least of which was recognizing the patient as a person in need of understanding. "I am amazed by what nurses accomplish in their everyday care. Nonheroic care can have quite heroic consequences."
Benner continues to contribute to nursing by creating a dialogue between science and nursing practice. Currently on sabbatical at Stanford University, Palo Alto, CA, and assisting with the development of a master's program in genomics, Benner is teaching ethics in relation to genomic medicine.
Although there are many exciting therapies out there based on genetic structures, Benner cautions against narrowing our gaze too much, much like Nightingale's admonition about the germ theory being the single causative agent. "What has excited me most over the years has been my own discoveries of the richness of actual nursing practice," says Benner. "We must use practice to guide scientific endeavors and we must also apply science intelligently to nursing practice."