Posted by: ayrshirehealth | July 20, 2012

Putting the ‘expert’ into expert practice. By @docherty_e

In the beginner’s mind there are many possibilities, but in the expert’s mind there are few:

Shunryu Suzuki.

“I don’t know.”

A simple statement to make, but one which many of us struggle with – I know I did.  Working as a clinician, in a relatively senior position saying, I don’t know can feel almost vertiginous – a personal challenge.  Particularly when it comes to direct care delivery.

  • The patients deserve a service where the people looking after them know the answers to clinical issues.
  • The staff should be able to expect an answer to their clinical questions.

But sometimes I’m not sure what the most up to date, or most evidence based answer is.

I should know!

To put this into context, I’m a nurse consultant. These posts are designed to allow senior nursing staff to remain in clinical practice. For many senior staff this has always been a dilemma.

As more and more clinical expertise is gained, career development has taken key staff into managerial roles. Nurse (and indeed Allied Health Professional) consultant posts have allowed an option to further develop these clinical skills and treat and care for patients directly. We work in a variety of areas but all have similar spheres of responsibility.

These are:-

  • Expert clinical practice
  • Professional Leadership
  • Education
  • Practice and service development
  • Research

In all of these areas the need “to know” is a key professional, and personal drive, but  it is in the field of clinical practice that this drive to know can be felt most keenly. It is in this field that all clinicians, whether medical, nursing or allied health professional, are aware of the potential impact of out of date, or incorrect knowledge. It can directly impact on the welfare of our patients. It can compromise care, prolong hospital stay or even lead to a poor outcome for that patient.

To keep our patients safe and to do no harm we need to be expert clinicians.

So what is an expert clinician?  Ericcson (2004) gave us a useful working definition.“Expertise has been defined broadly as the mastery of existing knowledge and techniques in a given domain.” As an example then, my clinical field is in the management of the acutely unwell adult. This means I need to have mastery of existing knowledge in fields as diverse as the  emergency management of asthma, diabetes, Coronary Heart Disease, delirium, sepsis and resuscitation. All expanding fields, all complex and demanding and to have complete mastery of them all, is unachievable.  I accept that.  I also have to deliver safe, effective and expert care to patients.

Perhaps this issue can be addressed another way. In re-defining nursing expertise in the United Kingdom, Hardy et al( 2006) identified a number of aspects to expert practice:-

  • Holistic practice knowledge
  • Saliency
  • Knowing the patient
  • Moral know how
  • Skilled know how

Skilled know how intuitively seems to echo the mastery mentioned previously but includes :-

  • Enabling others through a willingness to share knowledge and skills;
  • Adapting and responding with consideration to each individual situation;
  • Mobilizing and using all available resources;
  • Envisioning a path through a problem or situation and inviting others on that journey.

(Hardy et al,2006)

Clinical expertise

If we choose to think of clinical expertise including “mobilising and using all available resources” then it is possible to accept that an individual may not know everything about their field, but can rapidly access the resources to enhance any required knowledge.

One potential solution to facilitate clinicians in remaining expert and mobilizing resources is information technology. For  this to truly meet the needs of a complex clinical environment information technology will only make a significant improvement if it is available at the point of care.

The information clinicians require is available  yet  it takes 17 years to apply 14% of research knowledge to patient care (Balas & Boren (2000) but “information is only effective if it can be accessed….(and)…the user needs to be able to obtain the resource where and when she or he needs it” (Godard et al, 2010).

The interaction between the clinician and these information sources is largely inefficient (Moja and Banzi,2011). At home we use information technology efficiently and effective with a multitude of platforms. How many of us have smart phones, tablets and desk top systems at home and conveniently access knowledge networks and clinical  articles but cant do the same within the hospital setting to assist in the care of our patients?

Systems aren’t perfect

As clinicians working with patients we need to look at overcoming these obstacles. We need to embrace modern information systems to enhance our knowledge base and supplement our decision making skills. Active engagement with point of care Information Technology can help. The systems aren’t perfect and are still somewhat immature (Moja and Banzi, 2010) but if we can use it as a tool in our armoury to carry out expert clinical care and influence its development then we may reach a point of :-

I don’t know…(((click)))…..Ok – the current guideline is……….only slightly different from my current practice.

With an acceptance that you can’t be expert all the time.

References used in this blog

Balas EA & Boren SA(2000). Managing clinical knowledge for health care improvement. Yrbk of Med Informatics: 65-70

Ericsson KA.(2004) Deliberate practice and the acquisition and maintenance of expert performance in medicine and related domains.  Acad Med;79 (Suppl):70–81.

Goddard M, Mowat D, Corbett C, Neudorf C, Raina P and Sahai V (2004) Public Health Decision Making in 2010. Health Informatics Journal; 10(2): 111-119

Hardy S, Titchen A, Manley K & McCormack B (2006) Re-Defining Nursing Expertise in the United Kingdom.   Nursing Science Quarterly 19(3)

Moja,L & Banzi R (2011)Navigators for medicine: evolution of online point-of-care evidence-based services2010 Blackwell Publishing Ltd Int J Clin Pract 65, 1, 6–11L.

Next weeks blog comes from Andrew Moore, Assistant Nurse Director, looking at the value of reflective practice:

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Responses

  1. […] Putting the ‘expert’ into expert practice by Eddie Docherty on the Ayrshire Health blog. Share this:TwitterFacebookLinkedInPinterestMoreEmailRedditPrintDiggStumbleUponTumblrLike this:LikeBe the first to like this. This entry was posted in data, digital technology, medical practice, working practices by weeklyblogclub. Bookmark the permalink. […]

  2. Maybe the quest to improve access to clinical information at the point of care is being hampered by a focus on all of the possibilities, when starting with one might create sufficient mobilisation of confidence, ideas and evidence to start a movement – challenge for our clinical leaders in e-Health ?

  3. A very valid point. A number of ICU ward rounds now have a clinical librarian attached and their ability to access up to date information has been shown to dramatically influence decision making, using tablet platforms. I would suggest this is a very valid starting point that has potential impact on the culture of true evidence based practice and it’s implementation.

    But it’s in small pockets but if it becomes standard practice it may be the innovation that could make IT review of evidence at point of care the norm?

  4. […] us at this thought-provoking post about expert knowledge of clinicians by Eddie Docherty: Putting the ‘expert’ into expert practice (on the Ayrshire Health blog). How much are we ourselves online? John Patterson thought about the […]


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