Benner developed one of the best-known competency definitions in 1982 with her novice-to-expert model, which applied the Dreyfus Model of Skill Acquisition to nursing. It has been widely used as a tool to determine expertise.^4,5 Her model describes the five levels of expertise as:

• Novice: A beginner with little to no experience. Novices face the inability to use discretionary judgment and require significant supervision.
• Advanced beginner: Able to demonstrate marginally acceptable performance based on some real-life experience.
• Competent: Has usually been on the job for two to three years. At this level, the clinician has a sense of mastery and the ability to cope with and manage many aspects of patient care.
• Proficient: Able to grasp clinical solutions quicker and able to home in on accurate regions of the problem faster.
• Expert: No longer relies on analytics to connect to understanding of the problem but has an intuitive grasp and is able to zero in on the all aspects of the problem at hand without any wasteful or unfruitful possibilities.⁵

Benner maintains that knowledge accrues over time in clinical practice and is developed through dialogue in relationship and situational contexts.⁶ It should be noted that clinical experience is not the mere passage of time or longevity within a clinical experience but rather the actual level of clinical interaction. The clinician, therefore, may move forward or backward in the model, depending on the situation.

In the Benner model, the novices and advanced beginners would be prematriculants and students. You can see variations of this learning curve in different situations, whether it is a new clinician in the ED or an experienced clinician moving to a new practice.

Returning to the comment that prompted this article: when is an APP fully competent to see patients? There has been some good research in the last decade that demonstrates APPs have excellent patient care outcomes, even when taking into account the particular clinician level (novice through expert). The reality is that competence is acquired gradually, and even when APPs are far from fully competent, they can still see patients as long as the supervision is commensurate with the need.

A seasoned APP with emergency medicine experience will be more likely to hit the ground running, may work at a more rapid pace than a new graduate, and may be able to handle a higher volume of patients.

This is a challenging topic because what we do requires factual knowledge and the consistent, appropriate application of that knowledge. We know how to measure factual knowledge, more or less, but assuredly we don’t know how to measure the latter (possibly the most important part). In my opinion, we need a pragmatic approach to determine whether a clinician is competent and continues to be so.