(the majority) and home health agencies must meet certain minimum training requirements and competency standards and acquire state certification to become certified nurse aides (CNAs). An individual may become a CNA either by completing a nurse aide training program and a competency evaluation (a written or oral test and skills demonstration) or by passing a competency evaluation alone. A minimum of 75 hours of training is required through a state-approved CNA program, although many state programs exceed the minimum. At least 16 of the 75 hours must be practical training under the direct supervision of an RN or LPN. For CNAs working in nursing homes, states are required to keep a registry of those who have passed their competency evaluations (GAO, 2001b). There are no similar federal requirements regarding training, certification, competency evaluation, or registries for NAs working in hospitals (GAO, 2001b).

Experience and Expertise

Experience and expertise refer to the knowledge and skill obtained apart from (often subsequent to) formal preparation in an academic institution. Experience is acquired when an actual practice situation “refines,” “elaborates,” or “disconfirms” knowledge that has been acquired previously through the study of theory or principles or participation in events. Expertise is the result of an individual’s accumulation of knowledge and skill from such experiences (Benner, 1984:3–5). Thus, workers with similar formal education can possess varying degrees of expertise. A new graduate and a seasoned nurse of 20 years are both nurses, but their experience and expertise are very different.

The varying levels of expertise and skill acquired by learners have been identified through studies of different types of workers and learners within and outside of health care. These levels have been labeled as “novice,” “advanced beginner,” “competent,” “proficient,” and “expert” (Dreyfus and Dreyfus, 1986). As applied to nursing, they have been described as (1) novice—beginners who have no experience with the situations in which they must perform; (2) advanced beginners—individuals who have marginally acceptable performance based on a foundation of experience with real situations; (3) competent—individuals with 2 or 3 years in a similar situation; (4) proficient—wherein perception allows meanings to be understood in terms of the “big picture” rather than as isolated observations; and (5) expert—based on a wealth of experience enabling an intuitive grasp of situations and quick targeting of problem areas (Benner, 1984). According to this framework, expertise is subject matter–specific; thus, for example, RNs may be expert in one area of practice, such as critical care, but not in another, such as psychiatric nursing, just as a highly expert obstetrician may be less than proficient in managing an adult with neurological problems.



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