A Critical Evaluation Of An Aspect Of Expertise Nursing Essay

Published: 2021-08-12 00:45:06
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The simple definition of an expert is someone capable of doing the right thing at the right time (Holyoak 1991). After research on expertise several variations was observed on this definition. An expert can be defined as someone who performs at the level of an experienced professional such as a master or grandmaster in chess or a clinical specialist in medicine (Ericsson and Smith 1991). An expert can also be defined as top performer who excels in a particular field, for example elite athlete or musician, or that clinician who achieve the best clinical outcome (Rothstein 1999). Expertise is much more of a process or continuum of development rather than a static state resulting from a cluster of attributes such as knowledge and problem-solving skills or high level performance (Bereiter and Scardamalia 1993). Clinical expertise is viewed as a continuum along multiple dimensions, like clinical outcome, personal attribute such as:
Clinical reasoning (or practice decision making) is a context –dependent way of thinking and decision making in professional practice to guide practice actions. The model proposed by Higgs and Jones (2000) on clinical reasoning presented the process as an upward and outward spiral, a cyclical and a developing process including core dimension of knowledge comprising propositional and non-propositional, cognition or reflective inquiry utilising to process clinical data and metacognition which serves to bridge knowledge and cognition.
Clinical reasoning is the application of clinical knowledge and clinical experience towards a clinical presentation to drive a solution. Because treatment is dependent upon diagnosis, the ability to provide competent patient care is dependent upon the effectiveness and efficiency of clinical reasoning skills (Barrows & Feltovich 1987).
The current focus on clinical reasoning in physiotherapy is consistent with physiotherapist continued growth as a profession. The key trait of the profession is Autonomy which implies a defined body of knowledge and expertise in a domain. Merely application of theoretical or research based knowledge in practice is not professional expertise, it evolve from professionals use of critical analysis during and after their interaction with their patients, often in unclear or indeterminate situation (Kennedy 1987). For physiotherapist expertise develops in part through clinical reasoning.
Clinical reasoning is divided into diagnosis-reasoning, and management-reasoning (Edwards et al. 2004a p322). Within diagnosis reasoning there are two key strategies diagnostic reasoning and narrative reasoning. In this essay it is not possible to discuss both the strategies hence for further reading individuals are directed to Edwards et al. (2004a). In this essay more emphasize is given on one diagnosis-reasoning strategy identified; diagnostic-reasoning.
Diagnostic reasoning
Diagnostic reasoning is the formation of a diagnosis related to physical impairments and functional limitation(s), with consideration of associated pain mechanism, tissue pathology and the broad scope of potential contributing factors. While diagnostic reasoning is the most familiar reasoning strategy, in clinical practice it is combined with other strategies to establish patient rapport and to educate and promote patient self-efficacy and responsibility.
Diagnostic reasoning has many subthemes. Some of the subthemes that will be focused in this essay are pattern recognition, experience, structuring of knowledge, and memory also the contribution of knowledge in all these subthemes.
Researches in clinical reasoning in physiotherapy provide some evidence that similarity exists between clinical reasoning in medicine and clinical reasoning in physiotherapy (Payton 1985; Thomas – Edding 1987). Early studies conducted in medicine focused more on diagnosis and found that the clinical reasoning process used involved hypothesis generation and testing (Elstein et al. 1978; Gale 1982). The work of Elstein et al. (1978) was criticised stating that the reasoning used by expert in non-problematic situation was based more on pattern recognition as opposed to hypothetico-deductive reasoning (Groan and Patel 1985). Degroot’s (1996) conducted a study to look at the difference between the chess player with varying level of expertise and he found that chess master were able to recognize and reproduce chess pattern more quickly and accurately than novice players. Subsequent studies on chess (Chas & Simon 1973) and physic (Chi et al. 1981) revealed that expertise depended not only on the method of the problem solving but also on the expert’s detailed knowledge in a specific area, ability to memorize and ability to make inference.
Patel & Groan (1986) and Arocha et al. (1993) stated that hypothesis driven strategy, in which one reasons backward from a hypothesis and attempt to find data that elucidate it, is termed as backward reasoning. It is slower process which may make heavy demands on working memory. It is mostly used by novice who experience inadequate domain knowledge. The other strategy i.e., data driven strategy in which hypothesis is generated from data is termed as forwarding reasoning. It is mostly used by experts as it is based on the domain knowledge. Experts can make connections or inferences from the data by recognizing the pattern & link between clinical findings and a highly structured knowledge base. This explains why expert tend to ask fewer, more relevant questions & perform examinations more quickly & accurately than novice.
De Bono (1977) stated that by adopting pattern recognition approach the novice or unreflective practitioner might focus more on looking for the presence or absence of specific pattern & overlooks other potentially important information or find it difficult in seeing anything outside the most familiar pattern. Patterns can be rigid making recognition of variation difficult. This will lead to identification of pattern which lack sufficient information, where one or more key features are prematurely judged to represent a particular pattern. Metacognitive skills i.e., self-monitoring one’s thinking (cognition) is used by experts to detect inconsistencies or link between the data gathered, what they know from experience, and a critique of their reasoning process (Harris 1993).
Explanation of pattern recognition includes categorization and the use of prototype. Categorization involves the process of recognizing the similarity between a set of signs & symptoms, treatments option & outcomes from a previously experienced clinical case. The new case is placed in the same category as the past case(s) and is given the same label (diagnosis) (Brook et al. 1991; Schmidt et al. 1990). In the prototype model, experience results in the construction of abstract associations which convey the meaning assigned to symptom and signs (Bordage & Zacks 1984) or semantic relationships consisting of links between clinical features (Elstein et al. 1990).
Cervero (1988) emphasized that both declarative and procedural knowledge are required for skilled performance and sound clinical reasoning. Procedural knowledge involves recall and transformation of information, requiring critical analysis and deliberate action. Declarative knowledge initially provides data to guide action but after experience and repetition clinicians are able to perform without accessing declarative knowledge in familiar cases. Through reflective practice declarative and procedural knowledge is transformed into clinical knowledge. Importance to our ability to characterize the clinical reasoning of physiotherapist is the contention that in any field, a major difference between expert and non-expert is that expert has far more clinical knowledge (Cervero 1988). Clinical knowledge is predominately acquired through direct practical experience. Knowledge is particularly meaningful and accessible when it is created or acquired in the context for which it must be used (Jensen et al. 1999; Schon 1987; Shepard and Jensen 1990).
Resnik & Jensen (2003) discovered that years of experience and speciality certificate is not mandatory in achieving expertise. In their study some of the therapists classified as experts were relatively new physical therapist. Thus in their theoretical model, expert therapist knowledge base comprised of knowledge gained from personal experience, movement, rehabilitation, colleagues, patients, clinical experience, teaching experience, speciality work and entry level education as well as continuing education. A reflective therapist will learn from the collaborative experience if he recognizes his patient as source of knowledge. In order to validate their clinical pattern and procedural knowledge a therapist must continually reflect on their working hypothesis and the effect of their intervention just as the patient can be taught to problem- solve like to recognize various physical and psychological stressors. Batalden & Davidoff (2007) stated that experience, cognitive dissonance, reflection, self- regulation, and more experience are required for the development of diagnostic skill. The experience should include real patient and patient simulation cases that encourages openly generating and debating multiple hypotheses and then explicate, verbally and in writing, the pattern of if/then/therefore reasoning used. Experts learn from experience by using reflective inquiry or metacognition strategies to think about what they are doing, what worked and what did not work
In medicine, determination of proper patient diagnosis highly depends on the physician’s knowledge in a particular clinical speciality area, called case specificity (Elstein & Schwartz 2000; Riker & Paas 2005). In case specificity clinical experience & the feature of the case affect the problem solving strategy. Expert appears to have ability to combine these methods with knowledge and understanding of organizing the knowledge required to solve the problem (Boshuizen et al 2004; Brandsford et al 2000; Chi et al. 1988; Ericsson 1996). There is increasing evidence to support the importance of domain-specific knowledge expertise (Elstein et al. 1990; Hassebrock et al. 1993; Patel & Groan 1986). However for clinical reasoning expertise, the interaction between such knowledge and skills in reasoning are important. Boshuizen & Schmidt (1992, 1995) propose a stage theory of the development of expertise, which emphasizes the parallel development of knowledge acquisition and clinical reasoning expertise. This model emphasize that developing knowledge and the resultant reasoning expertise are largely the result of changes in knowledge structure. The development from novice to expert is accompanied by transition from biomedical knowledge by encapsulation of knowledge into concept clusters with clinically relevant foci to structuring knowledge around illness script & finally to instantiated scripts (actual detailed cases/ specific instances). This development in knowledge is accompanied by increasing expertise in reasoning. Hence expertise is linked to depth and organization of clinical knowledge.
Elstein et al. (1978) found that clinical problem solving expertise varied greatly across cases and was dependent on clinical knowledge in particular area. This highlighted the importance of clinical organization of knowledge. This view is exemplified by Custer et al. (1993, p.3) who stated, ‘for it is not the way problem are tackled, nor the thoroughness of the investigation, nor the use of problem –solving strategies, but the ability to activate the pertinent knowledge as a consequence of situational demand, which distinguish experienced from inexperienced physician’. In recent years various researches compared the comprehension and problem solving strategy of experts, intermediate, novice such as chess (Charness 1991) and physic (Chi et al. 1981) and it was found that the experts uses quite a different pattern of reasoning and organize their knowledge differently. Three important aspects are:
FIGURE 2. Important aspects of expert
Bordage and colleagues suggest that most diagnostic errors are not d result of inadequate medical knowledge as much as an inability to retrieve relevant knowledge already stored in memory (Bordage and Allen 1982; Bordage and Lemieux 1991). Development of poorly organized knowledge may be contributed by cognitive errors. Thus any consideration of clinical reasoning in physiotherapy must incorporate attention to cognitive skills. In order to grow in expertise, professionals need self-monitoring skills to plan, control and evaluate problem-solving knowledge and methods (Hassebrock et al.1993). Higgs & Jones (1995) discussed the importance of continuous self-monitoring or reflection on one’s think and it was stated that these processes assist clinician to detecting inconsistences in patient data as well as improving their organization of knowledge. This organization allows clinician to filter through patient information for familiar patterns.
According to the characteristics of experts identified by Glaser & Chi (1998) experts have superior short term & long term memory. Experts spend more time trying to understand the problem & they have strong self- monitoring skills. In clinical reasoning three forms of memories that are thought to be currently involved are sensory, workings (or short term memory) & long term memory. The clinician’s knowledge and experience need to be stored in mind with the capacities & limitation of these memories so that each type can be used most effectively (Carnevli & Thomas 1993). Sensory memory is the entry point of the memory system (Ashcraft 1989) and it is here that incoming stimuli from the clinical situation are either translated into mental presentation for transmission to working memory or they are lost (Coltheart 1983). Working memory can be likened to a processing centre or workroom of the memory system that temporarily takes in and uses mental information from both sensory and long term memory (Ashcraft 1989; Salame & Baddeley 1982; Waldrop 1987). To accurately describe and interpret clinical information received in working memory requires clinician to evolve qualitative and quantitative language or imagery in order to grow professionally.
Elaborative processing of information is thought to result in greater long term learning and more effective recall. It involves semantics, previously stored knowledge and clinical experience as a basis for processing current data (Carnevli). Conscious or unconscious recognition of cue patterns are the basis of most clinical judgements. This pattern recognition emerges from the knowledge and clinical experience previously stored in the long term memory. Any information in the form of chunk is stored in the working memory. An entire chunk is tagged and used as one unit. Clinician with sound theoretical knowledge and multiple experiences with particular phenomena will unconsciously chunk more items and integrate them at more sophisticated levels within their area of expertise (Corcoran 1986a, b). Repeated practice and building of efficient often complicated organizational system for storing information in long term memory allow clinician to move between working memory and long term memory so quickly that the boundaries between the two components of the memory becomes blurred, at this staged it can be stated that the clinicians has acquired skilled memory (Ericsson at al. 1980; Waldorp 1987). Schmidt et al. (1990) hypothesized that expert clinicians rely more on ‘patient instance script’ drawn from episodic memory for comparison with findings in the current situation as a basis for making clinical judgement.
Clinical practice expertise is a journey, an aspiration and a commitment to achieving the best practice that one can provide. Rather than being a point of arrival, expertise requires the capacity to recognize one’s limitation and practice capabilities and the ability to pursue professional development in a spirit of self-critique.
This essay aimed to demonstrate how different components of diagnostic reasoning contribute to the expertise in physiotherapy practice. This essay has shown various components that are majorly used by experts consciously or unconsciously than the novice. The limitation of this essay is only one reasoning strategy has been discussed, future study need to evaluate each of the clinical reasoning strategy as areas of expertise in physiotherapy.

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