Ever since the United Kingdom Central Council for Nursing, Midwifery and Health Visiting (UKCC) promoted the concept of advanced practice in the UK in the early 1990s, I have thought that to attempt to pin down advanced practice in the form of a definition, a set of standards or a list of competencies is to destroy the very thing that we are attempting to understand. However, to claim that advanced practice cannot be defined is not to say that it cannot be discussed and theorised. Thus, the typology of knowledge for advanced practice that I first advocated in the 1990s (Rolfe 1998), and which Christensen (2011) has recently revived and revised, proposed that we understand advanced practice in terms of the process of knowledge acquisition, in much the same way that Benner (1984) had earlier attempted to characterise expertise. In fact, my vision of the development of the advanced practitioner more or less followed Benner’s model of knowledge acquisition and simply added a further stage beyond expertise.
Indeed, it is Benner’s suggestion that the expert practitioner has moved beyond the constraints of practice based on propositional knowledge (that is, knowledge that can be expressed as formal logical or scientific propositions) that precludes expert or advanced practice from being precisely defined in terms of what the practitioner knows or does. My typology was, therefore, an attempt to conceptualise advanced practice in terms of the types of knowledge at the disposal of the nurse rather than the content or application of that knowledge, which, I argued, would vary from person to person and from situation to situation.
In a nutshell, I suggested that the typical career of the advanced practitioner proceeded as follows:
- 1 The novice student acquires a body of theoretical propositional knowledge from the classroom and from books and journals (propositional ‘knowing that’);
- 2 The novice then begins to apply that propositional knowledge to practice in a more or less mechanical or procedural manner (propositional ‘knowing how’);
- 3 Gradually over a period of time, practitioners modify their practice interventions as a result of experience, until they appear to the outside observer to be functioning almost entirely on ‘intuition’ at what Benner (1984) referred to as the level of expert (experiential ‘knowing how’).
Benner has documented this journey from novice to expert in some detail. She regarded expertise as the pinnacle of professional practice and suggested that the knowledge-base of expert practice could not be expressed in words (that is, it cannot be presented as propositional knowledge), but is rather unknown and unknowable, even to the nurse herself.
Whilst I largely agreed with Benner on the novice to expert trajectory, I found myself unwilling to accept her conclusion that intuitive expertise or ‘understanding without a rationale’ (Benner & Tanner 1987) is the final stage and the ultimate level of practice. Drawing on the work of Schön (1983), I argued that much of this so-called tacit expert knowledge was in fact propositional (albeit not based on generalisable propositions from scientific research), and I suggested a further stage that I referred to as advanced practice. The advanced practitioner consciously reflects on her so-called intuitive expert practice to generate explicit and explicable experiential knowledge from practice. Thus,
- 4 By reflecting and theorising on her experiential know-how, advanced practitioners are able to build a body of knowledge and theory from and about their own practice that they are able to articulate and pass on to less experienced practitioners (experiential ‘knowing that’).
As I pointed out at the time, it is not enough for advanced practitioners to practice what they preach; they must also be able to preach what they practice. This progression from novice to advanced practitioner is summarised in Table 1.
Whilst I welcome the attempt by Christensen (2011) to expand and develop my typology, I am not convinced that he has produced anything that was not present in the original. I would suggest that his additional categories of ‘knowing what’ and ‘knowing why’ are already present in my own categories of ‘knowing that’ and ‘knowing how’ and that these additions serve to confuse rather than elucidate in a number of ways.
First, Christensen’s (2011) alternative framework rather puzzlingly presents two different types of ‘knowing how’. As he points out, ‘it is less apparent what constitutes the difference between knowing how as the concept and knowing how as the knowledge in this framework’. He rightly adds, ‘Ideally, an alternative word would make this distinction clearer’ (Christensen 2011). Second, Christensen (2011) introduces the term ‘knowing why’ to mean roughly what Benner and I refer to as ‘knowing that’, and he uses ‘knowing that’ to mean knowing what to do based on all of the other types of knowing. It is difficult to see what purpose is served by this confusing change in terminology beyond the illusion that something new has been created. Third, he introduces the term ‘knowing what’ to refer to Benner’s concept of expert pattern recognition, in the mistaken belief that it was missing from my original typology. In fact, I refer explicitly to pattern recognition, in which ‘the expert practitioner “matches” a situation with a similar situation from a personal stored repertoire of paradigm cases’ (Rolfe 1998, p. 223), and locate it firmly in my category of experiential knowing how.
Confusion also arises from Christensen’s (2011) attempt to differentiate between advanced and advancing practice. On the one hand, he describes advanced practice as ‘a level of attainment that incorporates a myriad of qualities, skills and proficiencies’, whilst advancing practice is ‘a period of professional development prior to the advanced practitioner level’ (Christensen 2011). In other words, advancing practice is a kind of apprenticeship during which the qualities, skills and proficiencies of advanced practice are gradually attained. Elsewhere, however, he contrasts advanced practice as ‘an end-point of development’ against advancing practice as ‘a continual developmental process’. Clearly, if advancing practice is a continual process, the advancing practitioner can never attain the end-point of advanced practice, and the two concepts cannot, therefore, be part of the ‘continuum of development’ suggested previously. Furthermore, by considering the process of advancing practice and the ‘level of attainment’ of advanced practice as two stages in the same hierarchical model, he is committing what Ryle (1963) referred to as a category mistake. To add to the confusion, he also suggests that ‘advanced practice’ might refer to the discipline of nursing as a whole, whilst ‘advancing practice’ relates to the individual practitioner. Whilst acknowledging that advanced/advancing practice is a complex and contested term, Christensen (2011) appears to mix and match meanings and definitions throughout his paper, leading to a certain degree of confusion and inconsistency in his arguments.
Whilst Christensen (2011) is, perhaps, right to admonish my typology of knowledge for advanced practice for being ‘overly simplified’, his expanded account demonstrates some of the practical and semantic difficulties that writers will inevitably be confronted with in attempting to address the full complexity of the concept of advanced/advancing practice. At a time when the Nursing and Midwifery Council is once again considering the introduction of standards and competencies for advanced practice, it is important that we do not confuse the task of attempting to simplify concepts with that of reductionism.