Commentary on Christensen M (2011) Advancing nursing practice redefining the theoretical and practical integration of knowledge. Journal of Clinical Nursing 20, 873–881

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,