What Does “Clinical Expertise” Mean in Evidence-Based Practice?
Two weeks ago, I introduced the topic of evidence-based practice (EBP) and defined it as the integration of best evidence, clinical expertise, and patient preferences for clinical decision-making. Last week, I talked about the concept of “best evidence” and how nurses apply best evidence in practice. This post will deep dive into what clinical expertise really means to EBP. Next week I’ll finish up this series with explaining how patient preferences are used in EBP.
By the way, one of my free resources is an Evidence-Based Practice guide — print it out and use it as a quick resource for clinical practice. I’ll discuss each part of that handout in greater detail in my blog posts for this topic. Download this guide now!
What is Clinical Expertise?
EBP is NOT just the use of the best evidence the clinician can find – and in fact, in their early work, Sackett et al. (1996) made a point of saying that when making patient care decisions, EVIDENCE is NOT to be used by itself! The clinician’s clinical expertise – an accumulation of knowledge, patient care experiences, treatment decisions, and outcomes – is a critical part of clinical decision-making – but if used solely for decision-making, without integrating best evidence or patient choice, it’s not evidence-based practice.
“Evidence alone is never sufficient to make a clinical decision” (Guyatt et al., 2008, p. 6).
Clinical expertise means integrating the accumulated wealth of knowledge and information from patient care experiences and formal education as non-research forms of evidence for making clinical decisions.
Sackett et al. stated that it is the clinician’s “proficiency and judgment” gained from school, continuing education, and clinical practice experience that should be considered when making patient care decisions.
Clinical expertise is not just an afterthought. If clinical experience is not integrated, “practice risks becoming tyrannised by evidence, for even excellent external evidence may be inapplicable to or inappropriate for an individual patient” (Sackett et al., 1996, p. 71).
It is the clinician’s experience that hones their ability to diagnose and manage individual patient care situations. Evidence is used to inform diagnosis and management, but it is not the sole ingredient for EBP.
Without the incorporation of clinical expertise and patient preferences, best evidence could be used indiscriminately – just apply the latest study results from a population sample to an individual patient. For example, the clinician could use a validated algorithm of Yes-No decision points to choose an intervention without input from the patient. But the clinician may not interpret or answer the Yes-No decision points the same way the patient would. Decision trees or algorithms don’t work in every instance; Greenhalgh (2006) reminded us that people, and their situations, are complex; dichotomous decision paths could not possibly capture that complexity to be used perfectly in practice.
The values of the clinician and the patient may be at odds. Therefore, if the clinician doesn’t include the patient in the decision-making process, they could take risks or make recommendations that the patient would not otherwise agree to. Greenhalgh simply stated that ignoring the individual patient’s preferences and values discounted your individual patient for that of the average study patient — a sample from the population of interest.
Having determined the strength of the evidence and knowing the individual patient’s clinical circumstances, the clinician must judge the specifics of the evidence from the study to the relevance and feasibility of implementing the results in the clinician’s institution – thinking about differences in practice patterns, local medical or surgical expertise, monitoring capabilities, economic costs, etc. – and the likelihood of benefits to the individual patient (Guyatt et al.). The clinician needs to decide how their clinical experiences and the external evidence will (or not) benefit their patient and then clearly communicate that information to their patients for their consideration.
The founders of EBP so clearly presented the need for the incorporation of all three elements of best evidence, clinical expertise, and patient preferences to the practice of EBP, that I have always wondered why there was such resistance to this paradigm shift. I think that the resisters didn’t carefully read the many articles or books on how to practice EBP because many of their objections are countered in that literature. There definitely are challenges to practicing EBP as it is intended, but I think the benefits plainly outweigh the effort to change.
“External clinical evidence can inform, but can never replace, individual clinical expertise” (Sackett et al., 1996, p. 71)
Nursing and Clinical Expertise
Nurses have a lot of clinical expertise. First, you have academic knowledge – the knowledge from your studies to teach you how to be a nurse (LPN, ADN, BSN), and maybe further education for becoming an advanced practice nurse and nurse leader (master’s and PhD or doctor of nursing practice levels).
Then, you build on that “book learning” with knowledge and skills from clinical from taking care of many patients and dealing with physicians and other healthcare providers. Remember that feeling when the “light bulb came on” when you finally, really understood the patho behind a disease process because you cared for a patient with that problem? Nurses have expertise in how to talk with patients and elicit their feelings and their unique clinical concerns and how to explain procedures, tests, and the current situation.
Plus, a nurse believes in life-long learning! So you are reading the literature, using your skills to search for answers to clinical problems, and then evaluating the evidence. All of this knowledge and experience helps you to care for patients; anticipate their needs; deal with expectations from patients, families, and providers; and provide excellent care.
Bottom line: the component of clinical expertise in EBP is the efficient and effective use of the knowledge and skills clinicians have acquired in their education and clinical practice to accurately diagnose a patient problem, seek out the best evidence to solve that problem, identify the benefits and risks of potential care management decisions, and communicate knowledge in a way that patients can understand and thoughtfully participate in their care decisions, if they choose to.
Why Clinical Expertise Cannot Be Used by Itself to Make Clinical Decisions
What’s the problem with just using our clinical observations from our years of schooling and patient care to make clinical decisions? Isn’t that a benefit of being an expert?
An expert knows what they don’t know – and then seeks to know more!
There are many reasons for why clinical expertise alone is not sufficient for evidence-based practice.
First, we can’t know everything, right? No clinician’s clinical experiences or reading list will ever include the variety of diagnoses and problems of all the potential future patients that one might encounter. The EBP founders noted that for every patient encounter, the clinician can come up with multiple questions for which they don’t have an immediate answer (Dicenso, Guyatt, & Ciliska, 2005; Guyatt et al.; Straus et al., 2005). EBP has been called “just-in-time” learning for this very situation – it is a paradigm shift from the revered senior clinician who [acts like he] knows everything to acknowledging that even skilled clinicians don’t have all the answers!
After crafting patient-specific questions, the clinician searches for the strongest evidence they can find to answer those questions. Sometimes the best evidence will be found in systematic reviews or randomized controlled trials and sometimes the best evidence is from observational studies, qualitative research, or quality assurance data – the strongest evidence in the “hierarchy” all depends on what question was asked!
Remember that “Expert” opinion is not always expert. Greenhalgh warned that the expert’s knowledge may consist of limited clinical experience, outdated information, or their “life-long bad habits.” Even those with concentrated clinical experience in a specific area may be biased: they can be “so focused” that they fail to, or refuse to, see new evidence objectively.
The problem for those of us who seek out the “expert” to help us with a patient problem is that we can never be sure (unless we ask) if the expert advice is evidence-based and authoritative or merely their opinion and authoritarian-based. Straus et al. suggested that one way to discover whether you are getting evidence or opinion, is to directly ask the expert for their sources. You can politely ask if they can explain the basis for their answer and if they can share the references with you. “I’d love to really understand X, Dr. Smith, do you have a copy of the journal article I could borrow?”
Our personal clinical observations from patient encounters are unsystematic and therefore they are considered weaker forms of evidence according to the strength of evidence scales. (Typically, the more systematic the evidence/research process, the stronger the evidence.) While anecdotes or “illness scripts” are important sources of information about patients used in clinical and classroom teaching (e.g., grand rounds, classroom case scenarios), our recollections about these sources of evidence are not perfect (Greenhalgh; Straus et al.).
Because of our human flaws – flaws in what we remember, flaws in our actual memories (especially when those memories are many years since), flaws in how we recall information, and flaws in how we process information and make decisions, we are subject to misremembering and misinterpreting those observations. Consequently, when we rely on clinical experience only, we are making inferences for individual patients from a flawed dataset.
For instance, you may have treated patients, in the past, with a specific treatment, but that does not mean that treatment will work for your next patient. Our clinical experience, rich as it may be, still is limited by a relatively small sample size! So “all of my patients did well on treatment X” may only be a sample of 5 recent patients that you can remember.
Personal experience also can color one’s judgment. For example, it can be hard to make a decision to use a specific treatment on a patient, if you have had a bad personal experience with that treatment (on yourself or from witnessing a patient event). Or you might order or administer a common drug without thinking to monitor for a serious adverse effect, if you’ve never had patients who suffered from that adverse effect (Greenhalgh).
Clinical Intuition and Mental Shortcuts
Many nurses talk about clinical intuition. It’s a construct that can be associated with expert nurses and healthcare providers because clinical reasoning seems to occur without conscious thought.
It’s described as an instinct or “gut feeling” that “you just know.” For instance, that “something isn’t right” with a patient — when you suspect or anticipate problems that then transpire. I believe that clinical intuition used for clinical decision-making is primarily pattern recognition from the nurse’s past clinical experiences; it may also rely on accumulated knowledge from education and personal observations of the situation (Pearson, 2013). But remember: your recalled memories are not perfect – you don’t remember every data point, every action, every outcome.
If there is no hard research evidence to guide decisions, it is possible that nurses will rely on their imperfect clinical intuition or cognitive heuristics.
Cognitive heuristics are mental shortcuts or “rules of thumb” can assist in many situations, but may be misinterpreted or mislead in specific ones. Two examples of these mental shortcuts are the “availability heuristic” and the “representativeness heuristic” (Smith et al., 2002).
Availability heuristic: how likely is the outcome “according to how easily does one remembers (or how “available” are the memories of) patients who had the outcome”(Smith et al., 2002, p. 1615).
How this mental shortcut can mislead: clinicians may make inaccurate predictions based on “vivid memories” of death or complications of a few patients with a disease process.
Representativeness heuristic: “judging the probability of an outcome according to a patients’ resemblance to a “classic” or stereotypical patient who had the outcome” (Smith et al., 2002, p. 1615).
How this mental shortcut can mislead: clinicians may make inaccurate predictions based on what happens to the typical patient with this disease – even if the current patient has no signs or symptoms of adverse effects or complications.
Bottom line: Clinical expertise is an important and necessary piece of evidence-based practice, but it should not be the sole source of evidence when making clinical decisions.
Clinical expertise tempers the science of nursing with the art of nursing – it allows the clinician to evaluate the evidence in the context of clinical experience, the patient’s clinical state and circumstances, and the patient’s preferences for care.
What questions do you have on this topic of Clinical Expertise?
Let me know in the comments!
Don’t forget to download my free Evidence-Based Practice guide — print it out and use it as a quick resource for clinical practice.