Expertise has been defined as the outstanding performance and appropriate behaviour shown during an uncertain situation. However, Erricson Smith argued that expertise requires series of outstanding achievements under different circumstances. Additionally, Ericsson (1999) defined expertise as ability to take the right decision for a particular situation and performing it at the right time. Jensen et al. (1999: 23) had a totally different perception, that experts use specific knowledge to solve problems and the knowledge is learned by means of practice and experience. Therefore, a requisite for expertise is experience Benner (2001: 3). However, Higgs and Jones (2008: 123) said merely gathering of years of experience does not mean they will become experts. Experience is necessary for the attainment of expertise, but is not sufficient: some therapists do not attain expertise despite many years of experience. Therefore, it is not simply years of experience that is important; rather, to learn and grow, is considered to be vitally necessary for individuals (Jensen et al.1999). King at al (2008:110) stated extensive, focussed, and challenging experience is considered necessary, but very little is known about how much of, what type of experience is required for the development of expertise. Nojima et al (2003: 4) notes that expertise and experience are interlinked. However, in physiotherapy practice, it does not necessarily follow that with increased years of experience, the quality and quantity of care always improves.
Furthermore, Anon (1961) defined expertise as the skill or knowledge of a person who is highly experienced or has superior performance in a specific subject related to their study. However, Crosby et al (1990: 374) stated an expert is one who is ‘trained in a specialty area, either by education, experience, or both’. Furthermore, Higgs and Jones (2008: 123) stated expertise is continuous process of development rather than a static state resulting from different aspects like knowledge and problem-solving skills. The process of developing expertise is progressive, but not straight and continuous (Nojima 2003: 4).
Benner (1984) puts forth, using the Dreyfus model that in acquisition of development and skill, a student passes through five levels of proficiency: novice, advanced beginner, competent, proficient and expert. These stages from novice to expert highlight knowledge and decision making as essential requirements to expertise. In addition, Higgs and Jones (2008: 124) said expertise depended on detailed knowledge in a specific area, enabling them to distinguish the most critical and relevant information and to engage in effective action. Thus, expertise is a multi dimensional concept, these factors and characteristics serve the basis for understanding expertise (Jensen et al. 1999:23).
There is an unbelievable rate of change in health care system, and significant advances in physiotherapy. Therefore, it is very important to understand how physiotherapists achieve expertise which will help in effective and efficient management of patients (Jensen et al. 1999:12). Thus, it can be seen that various factors contribute in developing expertise; however, understanding developing expertise helps one to become an expert from a novice. One such factor that contributes in developing expertise and will be addressed in this essay is knowledge, with the main focus on practical knowledge.
KNOWLEDGE AND EXPERTS
“Knowledge is defined as an understanding of the facts (propositional knowledge), values (personal knowledge), and procedures ( knowledge derived from theory and research (Higgs and Jones 2011: 154) e.g. there are five lumbar vertebrae in a human vertebral column. Non propositional knowledge or ‘knowing how’ is created through practice and experience (Higgs and Jones 2011: 154) e.g. mobilization of joints. Non-propositional knowledge encloses tacit knowledge, practical knowledge and personal knowledge (self-knowledge) (Higgs and Titchen 1995: 526) e.g. of tacit knowledge is when a patient is made to stand from sitting, automatically the hand of the therapist supports the shoulder of the patient.
Jensen et al (2000: 28) stated reality and knowledge are socially constructed. That is, reality exists because we give meaning to it. Thus, the individual’s perceptions of reality, truth and knowledge have subjective dimensions or interpretations, as well as objective dimensions (reflecting the ‘world out there’).
Knowledge is considered as a dynamic phenomenon undergoing constant changes and testing (Higgs and Titchen pg 521). For e.g. an expert physiotherapist has more knowledge than the novice which increases with experience. (Novice is a person who is new to the field or work where he/she is placed).An expert physiotherapist learns from experience, what typical events to expect in a given situation and how to respond to it (Benner 2001: 28). However, Higgs and Titchen (pg 521) stated knowledge is the product of a dynamic and indeed difficult process of knowing, or striving to understand. In such striving, the individual’s depth and certainty of knowledge grows. For e.g.: An expert paediatric physical therapist collects multiple and selective cues through observation, handling of the child and conversation with the mother. The expert begins to see a pattern of motor delay that appears to be mild and knows the child would benefit from being encouraged to make specific movements whereas the novice physiotherapist applies an evaluation framework, testing reflexes that he can remember. He tests child in all position and does not observe any abnormal responses to the tests he applies. Therefore, he concluded that the child has no problem (Jensen at al 1999: 21) Furthermore, knowledge is essential for reasoning and decision making, which lie at the centre of physiotherapy practice (Higgs and Titchen pg 521) for eg: an expert physiotherapist has to have knowledge about rheumatoid arthritis to choose the correct intervention for treating it. Jensen et al (2000: 28) argued that differences between experts and novices lay primarily in experts’ recall of meaningful patterns, that is, in the structure of the knowledge rather than in a problem-solving strategy applied to the problem. In addition, they postulated that problem-solving expertise was case specific and highly dependent on the clinician’s mastery of a particular content domain.
Developing and changing forms of knowledge are critical aspects of student learning, as they help students move from memorization of facts or information to understand key concepts and structure of knowledge. For example, if a novice can grasp the critical concept of testing muscles in gravity and antigravity positions and knows muscle structure and function, memorizing specific tests is unnecessary. Instead the novice can rely on knowledge structures. (Jensen et al 1999 pg 22).However, Higgs and Titchen( pg 521) concludes that it is possible to deal with knowledge and knowledge claims, using a flexible framework which consists of the four key elements apparently common to all knowledge-oriented activities, i.e. social interaction, personal commitment, development of the mind, and value implication of knowledge.
Knowledge from one category can be transferred to other. For example: Practical knowledge can be transformed into formal, publically assessable propositional knowledge through theorization or rigorous critique. Propositional knowledge on the other hand also arises through basic or applied research. It can then be elaborated and arranged through practice to become part of the experience of individual (Higgs and Jones 2008 : 154).
Practical knowledge is associated with the interpretive paradigm and is embedded in the world of meanings and of human interactions (pg525 Higgs and Titchen). However, in medicine and the health care professions, propositional knowledge is more valued than practical knowledge (Higgs and Titchen: 525).However, as discussed practical knowledge is considered important for expertise (Higgs & Jones 2001: 154). Therefore, my focus will be on practical knowledge.
Smith et al (2003: 321) stated that it is both clinical and theoretical knowledge base, which enables physiotherapy experts to distinguish the most critical and relevant information and to engage in effective action e.g. in stroke rehabilitation, the expert knows how and when to make patients sit out of the bed whereas the novice will not make the patient sit thinking it is just two days of post stroke. However, King et al (2007: 224) argued experts can differentiate and selectively use the most important and relevant information because they possess structured and organized practical knowledge which provides a conceptual foundation. The practical knowledge of novice is stored haphazardly for e.g. a novice struggles to perform all the cranial nerve tests by memorizing the order of the tests, how is it performed and number of cranial nerves whereas an expert does it very easily (Jensen et al 1999: 32). Higgs and Jones (2011: 154) agreed that practical knowledge has supremacy over propositional knowledge by disagreeing to the medical model above, which follows rather than drives clinical knowledge. Furthermore, (Higgs and Titchen 522) argues that this compulsion of knowledge in its dependence upon propositional truth, limits acceptance and appreciation of non-propositional forms of knowledge. Although theoretical or propositional knowledge is useful in predicting the effectiveness of number of therapeutic interventions which might be helpful to the patient whereas practical knowledge helps the expert practitioner to use this theoretical knowledge in thze best interests of the particular patient or family member.
The knowledge and awareness that arise through reflection are considered to be essential ingredients for development of clinical expertise (King 2008: 190).The experts reflect and learn from their experience whereas novice are rigid. Experience is the enhancement of pre-conceived notions and theory through encounters with many actual practical situations that add differences to the theory (Benner 2001: 36)
It is this practical knowledge along with theory that makes enhancement possible for the experienced physiotherapist.
Practical knowledge is generated through describing and interpreting phenomenon, particularly human phenomenon, exploring it, taking account into context, subjective meanings and intentions within the particular situation (Higgs and Jones 2008: 157).
On the other hand, Benner (2001: 36) stated theory and research are generated from the practical knowledge, i.e. from the practices of the experts in a field. Moreover, expert physiotherapist relied on and utilized extensive physiotherapy knowledge to practice as compared to novice physiotherapists, who applied their existing theoretical knowledge to practice (Bonner 2007: 163). However, Jensen (1999: 33) argued that although experts posses more knowledge, it the organization and appropriate usage of that knowledge is important. Therefore, expert physiotherapists used multiple sources of knowledge in practice (Bonner 2007: 163). He also stated expert physiotherapists are better able to provide justification for their practice (Bonner 2007: 163). Experts continue to learn through experience by observing and scrutinizing their actions whereas novice’s thinking is governed by application of rules (Jensen 1999:17). Higgs and Titchen (1995: 521) stated physiotherapy experts construct their own knowledge rather than discovering it whereas novice rely on book knowledge and later apply it. Thus, knowledge is not simply transferred from the expert to novice; it is worked upon by the learner and incorporated into practice (Smith et al 2003: 324). Benner (2001: 2) stated there are many skills (knowing how) that are gained without knowing that. She also stated that one cannot always theoretically account for know-how for many common activities like swimming.
O’Hara (2012: 66) stated Physiotherapy is a practice focused activity and thus requires a great deal of practical knowledge. Benner (2001: 4) stated Practical knowledge is gained over time, and experts themselves are often unaware of their gains. Bonner (2007: 163) takes the statement further and stated for expert physiotherapists, the practical knowledge which they learnt in their postgraduate level had been proceduralized into their routine practice to the extent that it is difficult for them to indentify where they had learnt something e.g.an expert no longer measurse ranges of motion of any joint using goniometer. Expert physiotherapists know exactly which intervention to be used not only theoretically but also practically (O’Hara 2012: 66). Whereas with slighted change in symptoms the novice will not be able to decide the type of intervention. O’Hara (2012: 66) stated Practical knowledge acts as foundation of understanding from which therapists make informed decisions about how to act in mostly uncertain situations. Bonner (2007: 164) argued it is not only the practical knowledge, but also clinical cues by the patient which helps to make decision in complex situations e.g. a patient might position him in a way to relieve the pain symptoms from back.
Bonner 163: 2007 stated expert physiotherapist used multiple sources of practical knowledge to guide their practice. Moreover, Resnik et al (2003:1101) emaphasized experts use patient education as part of their practical knowledge to treat patients e.g. when a patient is taught what they have to do, why they have to do, then the patient automatically does it correctly so the work of the therapist lessens. King (2009: 186) argued that experts are more interested in observing how other expert therapists engage patients and in understanding the meaning of experiences for patients. Whereas the novice will not focus on other therapist and use their own rules of knowledge into practice.
Higgs & Jones (2011: 124) stated clinical reasoning brought progressive expansion of practical knowledge in a problematic situation that continued until the problem was solved e.g. when an intervention does not work, the physiotherapist reasons out for its failure. However, Jensen (1999: 266) argued clinical reasoning is theoretically quite simple but extremely difficult to apply in real clinical situations. Also, successful reasoning strategy might work in one can and may not apply in the second e.g. a low back ache patient might feel better with mobilization other may not.
The essay has demonstrated various aspects of knowledge and in particular practical knowledge which contribute in developing expertise in physiotherapy field. Practical knowledge is vital for skilful practice in physiotherapy. Efforts were made to appraise the best of literature and illustrate how expert and novice differ in practical knowledge and the effect on their clinical practice. This essay further concludes the importance and relevance of the practical knowledge in reference to developing expertise. Although, measures have been taken to appraise some of the key aspects of practical knowledge in depth. Other elements of practical knowledge can also be evaluated to develop expertise in the physiotherapy field.