Prescribing hand strengthening exercise for patients with rheumatoid arthritis; clinical cues influencing occupational therapists' and physiotherapists' judgements

OBJECTIVE

To explore the clinical judgements of therapists in prescribing the intensity of hand strengthening exercise in rheumatoid arthritis (RA).

METHODS

Phase I: Eleven therapists knowledgeable in treating patients with RA subjectively identified seven clinical cues. These were incorporated into 54 hypothetical patient case scenarios.

PHASE II

Therapists with ≥2 years post-registration experience and current or recent experience in treating patients with RA were asked to assess 69 case scenarios in total (54 + 15 repeats) and judge what intensity of hand strengthening exercise they would prescribe using the OMNI-Resistance Exercise Scale of perceived exertion. Using responses to the repeated cases, the Cochran-Weiss-Shanteau index of expertise was used to identify therapists who prescribed more consistently. Multiple regression was used to determine which clinical cues were most strongly associated with the intensity of exercise prescribed. A sub-group analysis explored differences between consistent and inconsistent prescribers.

RESULTS

Fifty-three therapists took part. Thirty completed all 69 case scenarios. Across all therapists, the three most important clinical cues associated with lower intensity of exercise prescribed were (1) Patient's reported pain intensity whilst practising the exercise (β = -1.150, p < 0.001), (2) Disease activity (β = -0.425, p < 0.001) and (3) average hand pain over the last week (β = -0.353 p < 0.001). Twelve therapists were categorised as consistent prescribers. This group relied on fewer clinical cues (three vs. seven) when judging what intensity of exercise to prescribe.

CONCLUSION

This study provides insights into how therapists prescribe hand exercises. Intensity of hand strengthening exercise was influenced by three key clinical cues, including pain intensity and disease activity.

The futility of decision making research

We have each spent more than 50 years doing research that has had little impact. Even more lamentable is that our field, judgment and decision making (JDM), has on the whole had little impact during that span. We attribute that failure to the use of methodologies that emphasize testing models rather than looking for differences in behavior. The "cognitive revolution" led the field astray, toward the goal of studying model fit rather than comparing observable results. With modeling as the goal, experimentation was stultified. Simple tasks became dominant. Although a poor metaphor for real decision making, the gambling paradigm has lasted forever because the inputs to the decision are known to the researcher and thus easily modeled.

An Empirical Approach to Identifying Subject Matter Experts for the Development of Situational Judgment Tests

Abstract. The development of a scoring key for the situational judgment test often requires subject matter experts (SMEs) to identify the best responses for a hypothetical situation. And yet, there is no gold standard for identifying the SMEs. This paper describes an empirical and context-free approach: the Cochran–Weiss–Shanteau (CWS) method, which does not rely on external criteria such as tenure or credential. We first describe the theory behind the empirical approach of expertise. We also outline the CWS method and provide an R script for calculating the CWS index. Next, we demonstrate how the CWS index can be used for improving interrater agreement and the efficiency of SME selection. Finally, we examined the nomological network of the CWS index. We found that the CWS index was associated with reflective thinking and intuition avoidance.

In-session interactive dynamics of the psychotherapy process between therapeutic alliance, therapist expertise, therapist technical intervention, patient metacognition and functioning

Empirical research has explored different dimensions of the therapy process and their associations, often showing bidirectional links: for example, metacognition may be favoured by a positive alliance with the clinician; on the other hand, metacognitive difficulties may be an obstacle for the alliance. However, little is still known about the overall relationship between multiple dimensions during the psychotherapy process. The aim of this study is to further explore the in-session interaction of therapeutic process variables, focusing on patient metacognition, therapeutic alliance, technical intervention, therapist expertise, and patient functioning. Participants included 45 patients involved in a psychodynamic weekly treatment in two clinical centres. Therapists were both in-training and experienced clinicians. Four instruments were applied on four psychotherapy sessions (178 verbatim transcripts): Metacognition Assessment Scale-Revised (MAS-R) assessing metacognition, Collaborative Interaction Scale (CIS) assessing therapeutic alliance, Psychodynamic Intervention Rating Scale (PIRS) assessing therapist technical interventions, and Shedler-Westen Assessment Procedure (SWAP)-200 assessing patient functioning. Sequential analyses revealed that specific therapist interventions co-occurred with three different levels of therapeutic alliance: a first one characterized by positive collaboration, the second one by neutral collaboration, and the third one by ruptures. Moreover, and critically, the patient metacognition, patient functioning, and therapist expertise were found to exert different effects in the three alliance levels. These findings suggest the existence of a specific interdependence between the variables involved in the research. These results further indicate that the therapist expertise is a key element in the therapeutic process, as it can drastically affect the in-session interactive dynamic.

Expertise among critical care nurses: A grounded theory study

OBJECTIVES

Explore critical care nurses' personal perceptions of expertise, expert performance and transition from novice to expert performer in clinical practice.

DESIGN

Following constructivist approach to grounded theory this investigation used qualitative open-ended interviews focused on the social construction of expertise in critical care nursing and the experiences of clinical practice that define that process.

SETTING

A multi-site urban area in the southeastern United States.

PARTICIPANTS

10 certified critical care nurses, three males and seven females, with 10-30+ years of critical care experience.

FINDINGS

Experience and knowledge are the foundation of expertise and expert performance. The higher the acuity the more frequent the experience the greater the nurses' aptitude and opportunity for learning and professional growth. It was also noted that self-actualisation was a major determinant in the development of expertise in critical care.

CONCLUSION

Key findings suggested that clinical experience and personal motivation combined with self-actualisation, the drive to maximise personal potential, determine critical care nurse's trajectory towards professional excellence. Expert performance evolves over time. Knowledge acquisition and experience have an interdependent reciprocal relationship inferring that you cannot have one without the other. Social expectations and experiences have a direct impact on professional aptitude and development if expertise.

Professional expertise amongst speech-language therapists: “willing to share”

Purpose

The current healthcare environment provides several challenges to the existing roles of healthcare professionals. The value of the professional expert is also under scrutiny. The purpose of this paper is to generate a construction of professional expertise amongst practitioners in the current healthcare environment. It used the speech-language therapy community in New Zealand (NZ) as an example.

Design/methodology/approach

Speech-language therapists currently practicing in NZ completed an online survey including qualitative and quantitative components. The range of experience and work settings of participants (n=119) was representative of the workforce.

Findings

Participants clearly identified being “highly experienced” and “having in-depth knowledge” as essential elements of professional expertise. Thematic analysis generated two interconnected themes of a professional expert being a personal leader and teacher, and a highly experienced, knowledgeable and skilful practitioner. Additionally, practitioners needed to be seen to contribute to the community in order to be known as experts. Clinical practice was valued differently from research generation.

Originality/value

This study is novel in exploring a construction of professional expertise amongst practitioners in a current healthcare community. Within that community, experts could be viewed as highly effective practitioners that visibly contribute to the professional community. The study draws attention to the role of reputation and the impacts of being a clinical teacher or leader compared with pursuing a research role. This could be particularly relevant in the promotion of evidence-based practice.

Reflections on the Power to Define Psychotherapy Expertise

The field of psychology has struggled to define what it is that makes an expert therapist expert. Just as elusive has been the ability to know and articulate how one achieves expertise as a therapist. In their major contribution, Hill, Spiegel, Hoffman, Kivlighan, and Gelso identify a number of constructs that researchers interested in assessing expertise can consider and evaluate. In this reaction to their article, we share where we are in agreement with the authors and where our thoughts diverge. We conclude with what we deem to be missing from this discussion regarding therapist expertise—power and privilege as it relates to who decides what makes an expert.

Therapist Expertise in Psychotherapy Revisited

The thesis of this article is that the lack of evidence related to the identification and development of therapist expertise is due to the inadequate definition and operationalization of the concept. We propose a definition of expertise that is restricted to performance in the conduct of psychotherapy: the manifestation of the highest levels of ability, skill, professional competence, and effectiveness. In addition, we offer several criteria that may be used to assess expertise: performance (including relational and technical expertise), cognitive processing, client outcomes, experience, personal and relational qualities, credentials, reputation, and self-assessment. We then review research related to the development of expertise, highlighting the role of experience with clients, personal therapy, supervision, deliberate practice, and feedback. Finally, we conclude with recommendations for conducting research on therapist expertise.

A cognitive model for aggregating people's rankings

We develop a cognitive modeling approach, motivated by classic theories of knowledge representation and judgment from psychology, for combining people's rankings of items. The model makes simple assumptions about how individual differences in knowledge lead to observed ranking data in behavioral tasks. We implement the cognitive model as a Bayesian graphical model, and use computational sampling to infer an aggregate ranking and measures of the individual expertise. Applications of the model to 23 data sets, dealing with general knowledge and prediction tasks, show that the model performs well in producing an aggregate ranking that is often close to the ground truth and, as in the "wisdom of the crowd" effect, usually performs better than most of individuals. We also present some evidence that the model outperforms the traditional statistical Borda count method, and that the model is able to infer people's relative expertise surprisingly well without knowing the ground truth. We discuss the advantages of the cognitive modeling approach to combining ranking data, and in wisdom of the crowd research generally, as well as highlighting a number of potential directions for future model development.