In Pursuit of Expertise. Toward an Educational Model for Expertise Development

Advances in Health Sciences Education 9: 107–127, 2004.© 2004 Kluwer Academic Publishers. Printed in the Netherlands.

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In Pursuit of ExpertiseToward an Educational Model for Expertise Development

BRUCE C. DUNPHY1,∗ and STACEY L. WILLIAMSON2

1Department of Obstetrics and Gynaecology and the Division of Medical Education, Room G2141,5980 University Avenue, Halifax, Nova Scotia, Canada, B3H 4N1; 2The Women’s Health Program,IWK Health Centre, Halifax, Canada (∗author for correspondence, e-mail:[email protected])

Abstract. Firstly, the many characteristics of expertise are examined: they include aspects of patternrecognition, knowledge, skill, flexibility, metacognitive monitoring, available cognitive space andteaching abilities. Secondly, three educational models from different domains (Nursing, SurgicalEducation, Education) are analysed, compared and contrasted, in relation to both educationalapproach and the development of expertise. Thirdly, a new model for the development of expertiseis proposed, incorporating aspects of each of the three previously discussed models. Within thisnew model, four phases of development are proposed, culminating in the achievement of expertise.Furthermore, it is noted that under certain circumstances performance can deteriorate, and that withappropriate support, there can be recursion back through earlier phases of development. Significantimplications for both healthcare education and practice are discussed, in relation to concepts ofexpertise, potential educational approaches and the proposed model for the development of expertise.

Key words: assisted performance, expertise, experiential learning, phase, psychomotor, skill, zoneof proximal development

Introduction

As healthcare knowledge and technology advance rapidly, there are increasingdemands upon practitioners both to keep up to date by taking part in formalcontinuing education and recertification programs, and to maintain a high standardof practice under the watchful eye of patients, administrators and professionalbodies. There is an expectation that practitioners should be (remain) expert in theirfield(s) of practice. Consequently, a clear understanding of what expertise is andhow it may be achieved, is of considerable importance for planning both servicedelivery and healthcare education (at all levels) including program design and anti-cipated educational outcome(s). Furthermore, an understanding of expertise maybe relevant to considering both the relative role(s) and the educational processesfor different types of practitioners. For example, in the medical domain this mightinclude how to educate family physicians, specialists and sub-specialists, regardingthe same subject matter, and what level of skillfulness should be expected fromeach group at the end of an educational program. Therefore, as we believe thatconcepts surrounding expertise are important, within this manuscript we will

108 BRUCE C. DUNPHY AND STACEY L. WILLIAMSON

examine both characteristics of expertise, and examples of approaches to educationin healthcare areas where expertise is required.

Medical diagnostic expertise has been extensively reviewed elsewhere, inclu-ding a proposed model for acquiring such expertise (Schmidt et al., 1990), illnessscripts (procedural knowledge related to medical diagnostics), and the role of bothpattern recognition and memory (Rikers et al., 2002; Eva et al., 2002; Charlin et al.,2000; Custers et al., 1996; Norman et al., 1992; Schmidt et al., 1990; Norman etal., 1989; Norman et al., 1987). Consequently, such expertise will not be discussedfurther within this manuscript, and we will analyze, compare and contrast modelsobtained from other aspects of healthcare and education. In our outline and compar-ison of educational models obtained from different domains (Medicine, Nursingand Education) we will both examine educational approaches, and assess whethereach model includes strategies for the development of expertise.

The Expert

Dreyfus and Dreyfus (1986, 1996) summarized the qualitative and quantitativedistinctions inherent in differing levels of skillfulness. The expert has high levelsof procedural knowledge and skills (knowing how) as well as declarative knowl-edge (knowing what), and contextual flexibility (knowing when and where). Expertperformance does not rely on principles or rules to connect understanding ofthe situation to an appropriate action. Experts are so at home in their domain(s)that they may be unaware of invoking skills as they proceed. Low level androutine problem solving and decision making do not typify expertise. When thingsare proceeding normally in the practice situation, expertise issues in doing whatnormally works. However, expertise does not preclude conscious deliberation. Onthe contrary, as declarative and procedural knowledge in the expert are automatedto a large extent, there is additional cognitive space available to consider alter-natives and reflect upon progress. Thus, an expert seems to be able to considermore possibilities and can focus attention on the key information more effectively.Consequently, an expert in an area of healthcare can devote additional cognitivespace to considering the individual nature of the patient’s unique presentation andpoint of view, or to planning the best approach to a complex type of care.

Metacognitive monitoring of ongoing actions is the capacity to remain awareof the whole situation, to monitor events as they occur, to reflect on alternativepossibilities should a decision need to be made, and to maintain the “mental space”to reflect on processes that are happening skillfully/automatically (Garofalo, 1986).This kind of monitoring is a feature of expertise, and is made possible by not beingrequired to direct limited cognitive resources to more mundane (automated) aspectsof a task.

Bransford et al. (1999) outlined the following important characteristics ofexpertise. First, experts recognize features and meaningful patterns of informationthat are not noticed by novices. For example, an expert clinician may be able

ACQUIRING EXPERTISE 109

Table I. Characteristics of expertise

Area Feature of expertise

Pattern recognition Recognition of complex patternsKnowledge High levels of declarative and procedural knowledge

Organized reflecting a deep understandingConditionalized on sets of circumstancesCan flexibly retrieve with little attentional effort

Skills Performance of skills may be automatic

Cognitive space As knowledge automated, additional cognitive space available fordeliberation

Metacognitive monitoring Skillful/automatic monitoring of whole situation

Teaching ability Not necessarily good teachers

Flexibility High levels of contextual flexibilityCan consider more possibilities than average practitionerVarying levels of flexibility in approaches to new situations

to extract key pieces of information from a patient’s details, which he/she thencombines (pattern recognition) to make a diagnosis that would not be immediatelyapparent to a novice clinician. Second, experts have acquired a great deal of contentknowledge, which is organized in ways that reflect a deep understanding of theirsubject matter. For a healthcare specialist, this depth and organization of knowledgemay only result from devoting a considerable amount of time to limited area(s) ofpractice.

Third, experts’ knowledge cannot be reduced to sets of isolated facts orpropositions but, instead reflect contexts of applicability: that is knowledge is“conditionalised” on a set of circumstances. Fourth, experts are able to flexiblyretrieve important aspects of their knowledge with little attentional effort. Fifth,although experts know their disciplines thoroughly, this does not guarantee thatthey are able to teach others. Thus, to be good teachers, healthcare experts mustalso have expertise in teaching/coaching (Tharp & Gallimore, 1988). Sixth, expertshave varying levels of flexibility in their approach to new situations.

Table I summarizes key characteristics of expertise. Clearly, these concepts areimportant considerations when planning approaches to healthcare education, fromthe point of view of both promoting teaching expertise and assuring expertise atproviding patient care. As the ability to teach well is not automatically present atthe same time as other forms of expertise, attention to how to help service deliveryexperts develop educational skills may be important. However, clinical/technicalexpertise is required to be an effective teacher, in order to be able to extractimportant information for the learner, divide tasks into goals and sub-goals and


grade tasks by level of complexity. A potential implication for service deliveryof characteristics of expertise, is that it may be necessary for specialists to restricttheir area of clinical practice in order to become expert in an area. Such an approachwould allow practitioners to keep abreast of the extensive literature relating to theirsubject, and develop a high level of performance in any related technical/surgicalskills and procedures.

Having defined expertise, we will now outline and compare and contrasttheories of how a high level of practice performance may be acquired, that havebeen obtained from different domains. Firstly, a model of experiential (trial anderror) learning obtained from the Nursing literature will be examined, followed bytwo models of skill acquisition (psychomotor surgical skill acquisition obtainedfrom the Medical literature, and the Zone of Proximal Development obtained fromthe Educational literature).

Trial and Error (Experiential) Learning

Benner et al. (1996a–d) and Dreyfus and Dreyfus (1996) have reviewed and appliedtheories of experiential (trial and error) learning to the field of nursing. In collab-oration with Dreyfus and Dreyfus, Benner et al. (1996a–d) undertook a six-yearinterpretive study of narratives of practice generated by 130 hospital nurses (mostlycritical care). The study findings lead to an adaptation for nursing practice ofmodels of expertise originally proposed by Dreyfus and Dreyfus (1982, 1986).Benner’s model of expertise is the one that is predominant quoted within thenursing literature, and recently Martin (2002) demonstrated that there is some asso-ciation between level of expertise as defined by Benner and both critical thinkingand decision making.

In their model, Benner et al. (1996a–d) described five levels of expertise(novice, advanced beginner, competence, proficient and expert). The first fourphases of learning (novice, advanced beginner, competence and proficient) can bedescribed as calculated rationality, whereas the expert is characterized by deliber-ative rationality/meditative deliberation. The authors describe how learners acquire“intuition”, and their description of such intuition appears very similar to complexpattern recognition.

NOVICE

The term novice is self-explanatory, being someone that is completely new to anarea and who does not possess a significant amount of pre-existing knowledge orskills.

ADVANCED BEGINNER

After a period of approximately one year of exposure to a field, a novice progressesto become an advanced beginner. Benner et al. (1996a) indicated that most new


graduate nurses are at the advanced beginner level. The advanced beginner ischaracterized by feelings of both inadequacy and responsibility. Learners at thisstage self-judge (self-criticize), and have a range of acceptance/reliance upon theirown clinical judgement. Advanced beginners are task-orientated, tend not to seethe whole picture, delegate complex decision-making to acknowledged experts,and ask lots of questions of experts.

COMPETENT

An advanced beginner typically progresses to become competent after one anda half to two years’ practice (Benner et al., 1996b). The competent practitionerdemonstrates both increased organizational ability and technical skills. They takeon increased responsibility and begin to recognize the fallibility of colleaguesand co-workers (become discriminating about others’ performance). Consequently,they have diminished trust in the performance/ability of coworkers, and indeedhave been described as reaching a crisis in confidence regarding coworkers.Competent practitioners are beginning to develop both the ability to recognizewhen the “system” isn’t working, and to recognize the limit(s) of scientific knowl-edge. However, such practitioners have a limited ability to integrate domains, suchas clinical knowledge and ethics.

When competence is achieved, general performance is more fluid and coordin-ated, and such learners have an increasing ability to handle complex situations.Competent practitioners perform well in familiar situations, and anticipate typicalprogressions of situations. They recognize patterns that are in keeping with typicalsituations, are beginning to recognize when there is deviation from such patterns,and are uncomfortable when the progression of a given situation is atypical (failedexpectations). Competent practitioners are beginning to think about deviating fromstandard approaches to given situations, individualizing patient management/care,to examine whether there is room for flexibility/variability in approaches that theycan take, and may be beginning to develop an individual “style”.

Benner et al. (1996b) believe that at this stage of learning, emotions (such asfeeling overwhelmed, disappointment or elation) have a significant impact uponperformance, by sharpening perceptual acuity. However, the competent practitioneralso struggles with the potential detrimental impact upon performance of emotionalover-involvement and/or excessive emotional detachment.

PROFICIENT

Benner et al. (1996c) indicate that proficiency is more common between twoand three years after entering nursing practice, and that once this level has beenachieved by a learner, then with additional experience they usually become anexpert. Entry into proficiency marks a crucial shift in a practitioner’s perceptualability to both read a given situation and respond appropriately. Things begin


to just stand out as being more or less important/relevant. Benner et al. (1996c)view this as the development of new perceptual and relational skills, which in turnreshape the practitioner’s capacity to perform. This does not occur merely by thepassage of time, but rather as an active transformation of both perceptions andexpectations. Such practitioners are able to recognize similarities and differencesbetween current and past situations, are open/responsive to new situations/change,and are able to reflect when presented with a new situation. They are able to seethings/patterns clearly, but in general have to think about/reflect upon the bestcourse of action. The proficient practitioner has developed a perception of both timeand reasoning through observed transition(s). Less attention is needed to executeskills, and task performance is both smoother and quicker.

Again, the authors indicate that further development of emotional responsive-ness is important in achieving proficiency, such as an emotional awareness whena situation is changing, atypical/unusual situations occur or something is goingwrong. Proficient practitioners are learning the skill of how to balance emotionalinvolvement (not becoming either too involved or too detached).

EXPERT

Benner et al. (1996d) indicate that expert practice is characterized by increasedintuitive links between seeing salient issues/points and responding to them. To theexpert, the response to a given situation is self-evident/obvious. Experts are ableto see the big picture, see situations in different ways and weigh alternatives. Theyhave a sense of the future, timing and pace (including time pressures/constraints),and can recognize anticipated trajectories. Experts have expanded peripheral vision(noticing all events rather than just the main focus of activity), and are attuned tothe skill level of other practitioners. Consequently, they are more able to recog-nize potential/actual hazards, and are a resource both for surveillance and trainingof other practitioners. When compared to the proficient practitioner, task perfor-mance/the response to a given situation is even smoother and appears almostseamless. The expert’s emotional responsiveness varies depending upon the needsof a given situation.

In experts, a number of aspects of performance are inter-linked, so as to enhanceoverall performance. These include response-based practice, embodied know-how(salient knowledge just stands out), seeing the big picture, and seeing the unex-pected and beginning to search for explanation(s). There is linked expert judgementand action/performance.

Phases of Psychomotor Surgical Skill Acquisition

We undertook an extensive review of the surgical literature, and found that Fittsand Posner’s (1967) three-stage model for psychomotor skill acquisition is widelyconsidered to be how surgical skills/techniques are acquired (Kopta, 1971; Lippert


et al., 1975; Lippert & Farner, 1984; Kaufman et al., 1987; Hamdorf & Hall, 2000).However, this model remains to be validated within the surgical domain. Fitts andPosner’s (1967) original account was contained within a psychology textbook onhuman learning, and did not indicate whether their model was based upon intu-ition, systematic observation or experimentation. Scientific evidence to support thevalidity of this model was not presented. However, this three-stage model is extens-ively quoted and applied in a number of domains, including psychology, aviation,the military, human motor development, various sports and surgical education.Within the literature, we have not been able to find studies that validate this model,although with such a wide range of potential applications evidence may exist thatwe have not detected.

The stages of development of motor skills that can be acquired during surgicaltraining have been reviewed by a number of authors (Kopta, 1971; Lippert et al.,1975; Lippert & Farner, 1984; Kaufman et al., 1987; Hamdorf & Hall, 2000). Fittsand Posner (1967) indicated that the acquisition of psychomotor skill occurs inthree distinct, yet overlapping stages; the cognitive, the integrative or associative,and the autonomous phases. In the cognitive phase the learner intellectualizes whatthey want to do, and then plans the steps necessary to accomplish the task. Cessa-tion of training at the end of the cognitive stage does not facilitate psychomotorskill acquisition. Once the cognitive element has been acquired, the process ofintegrating this knowledge into appropriate motor behavior can be initiated.

The associative stage is a stage of practice and repetition, and the student gradu-ally begins to approximate the goals of the practice. The associative stage involvespractice, but not indiscriminate practice. During this phase of psychomotor skillacquisition, knowledge of results becomes an essential part of the training process.Knowledge of results is evaluation information, (visual, auditory, tactile), providedto the learner after the completion of the task relevant to the adequacy of perfor-mance on that practice trial. No learner can acquire adequate psychomotor skillswithout the presence of knowledge of results (Newell, 1974). There may be greatpotential harm for a learner to practice and not know either if they are performingadequately, or what must be done to correct any errors. In the psychomotor domain,undesirable patterns may be difficult to correct once they become established(Fleishman & Parker, 1962). Consequently, there should be minimum exposureto undesirable patterns during an effective skill teaching program.

The importance of knowledge of results to the acquisition of psychomotor skillsbecomes more apparent from an understanding of the psychomotor skill acquis-ition process. As learners practice psychomotor tasks, they generate a feel forthat task called feedback, which is usually received as a result of proprioception.Feedback on its own should not be considered to be evaluation information. It isonly how that particular practice trial or attempt feels to a learner. After a task hasbeen completed, the learner must receive knowledge of results in order to securepsychomotor skill acquisition. Adams (1971) theorized that the learner makes acomparison between knowledge of results and the feedback information that was


generated during the performance of the task, in order to identify and understanderrors that were made in the previous attempt. Consequently, after the completionof a task, the learner compares the feel of the task (feedback) to the evaluation ofthe task adequacy (knowledge of results) in order to generate error information.Error information is used during attempts to upgrade the feel of the task (feedback)and consequently improve performance. Where a series of attempts is combinedwith knowledge of results, a learner will gradually shape performance toward thedesired end. However, if knowledge of results is not provided to learners, errorinformation cannot be upgraded.

Knowledge of results can be provided to learners in two ways. Firstly, sometasks have knowledge of results built into them, which is called intrinsic knowledgeof results. However, it should be noted that this obviousness may itself be the resultof extensive anatomical and biological knowledge (knowing where to look, andknowing what information within the situation is the key information). Sometimes,expertise may be required (a rich base of knowledge that is automated and readilyavailable, knowledge that is highly integrated and useable), in order to recognizewhere and when tasks have knowledge of results built into them. Consequently,without help the learner may not recognize many forms of built-in knowledgeof results. Secondly, if intrinsic knowledge of results is not readily available, itbecomes the responsibility of the instructor to provide augmented knowledge ofresults. Augmented knowledge of results is evaluation information provided afterthe completion of a task from a source outside of that task. Consequently, theinstructor should focus upon two areas whilst teaching surgical skills. Firstly,the learner is assisted through the cognitive stage of psychomotor skill acquisi-tion by an intellectual analysis and discussion regarding the task to be acquired.Secondly, during psychomotor skill acquisition, the instructor provides augmentedknowledge of results to the learner.

During the integrative phase, performance tends to be irregular with each stepof the task easily identifiable. Practice gradually results in the evolution of motorlearning to the stage where routine execution no longer requires cognitive input(for some skills, much practice and experience may be required to reach thisstage). When this level of independence is achieved, learning has reached theautonomous phase and performance becomes smooth, automatic and resistant tostress. Consequently, one of the psychomotor goals of all training programs couldbe to have trainees or specialists reach the autonomous stage.

Fitts and Posner (1967) stated that the continued use of cognitive processesduring the performance of a psychomotor skill may greatly slow or inhibit theperformance of that skill. This point will be reexamined in our discussion, as itis very relevant to the distinction between autonomous performance of a skill andexpert performance of a task.

Retention of psychomotor skills is defined as the amount of time a skill can besatisfactorily performed after practice has ceased. Whilst a trainee is performingdaily functions, they are receiving inadvertent practice. However, this practice may


not be systematic or great enough to lead to retention. Therefore, the conceptof over-learning can be applied. Over-learning is the continued practice of apsychomotor skill after that skill has been mastered, in order to enhance reten-tion. Over-learned skills are retained, and thus training programs should notstop psychomotor training after a skill has been acquired or mastered but mustcontinue to allow systematic practice of that skill in keeping with the principle ofover-learning.

Instructors in psychomotor skill acquisition should establish on an intellectuallevel the relevance of both practice sessions and specific tasks. Consequently, allpractice skills should be compared to completed task analyses. Furthermore, thereis a significant interaction between a learner’s level of interest and their ability toacquire psychomotor skills. Unmotivated learners are less likely to acquire suchskills, and “going through the motions” of a practice session is unlikely to leadto adequate skill acquisition. However, if learners are motivated and focus on theprecise aspects of the practice session, skill acquisition is likely to be enhanced.Motivation may be improved by establishing the relationship between the prac-tice session and the performance of skills that will be needed as a professional.A learner should be aroused enough to focus on the task. However, excessivearousal or anxiety may be detrimental to a learner’s ability to acquire psychomotorskills. The relationship between arousal and motivation is more complex than isdescribed in the psychomotor literature (Weiner, 1986; Biggs & Telfer, 1987; Gage& Berliner, 1992). The association between arousal and motivation follows a U-shaped curve. If there is too little arousal, a learner may simply not be motivated toengage in an educational activity. However, if there is too much arousal there maybe interference that results from stress and anxiety. An optimum level arousal liessomewhere between these two extremes. However, motivation may not simply bea physiological state. Motivation can be viewed as an aspect of planning, engagingin and evaluating behavior. Consequently, motivation involves cognitive processesthat lead to arousal and mobilization of physiological processes.

Assisted Performance and the Four Stages of the Zone of ProximalDevelopment

Vygotsky’s Zone of Proximal Development was proposed after systematic obser-vation of children who were learning language skills, and it has been validated inrelation to outcome in some areas such as occupational therapy, child developmentand educational psychology (Ratner, 1984; Belmont, 1989; Exner, 1990; Meijer &Elshout, 2001). Furthermore, other aspects of Vygotsk’s theories have been appliedto undergraduate surgical education, leading to a significant improvement in theperformance of basic surgical techniques (Qayumi et al., 1999).

Assisted performance defines what a learner can do with help, with the supportof the environment, of others and of the self. The contrast between assistedperformance and unassisted performance identified the fundamental nexus of


development and learning that Vygotsky describes as the zone of proximal devel-opment (ZPD) (Vygotsky, 1978). For any domain of skill, a ZPD can be created.In the ZPD, assistance is provided by the teacher, the expert, and the more capablepeer. Distinguishing the proximal zone from the developmental level by contrastingassisted versus unassisted performance is of major importance in understandingapproaches to education. It is in the proximal zone that teaching may be defined interms of learner development. Teaching is good only when it

“awakens and rouses to life those functions which are in a stage of maturing,which lie in the zone of proximal developmental” (Vygotsky, 1956, p. 278).

Consequently, teaching consists in assisting performance through the ZPD.Teaching can be said to occur when assistance is offered at points in the ZPDat which performance requires assistance.

Learning within the ZPD can be divided into four stages. Stage one is whereperformance is assisted by more capable others. The amount of outside regula-tion depends upon the nature of the task and the characteristics of the learner. Inthe early stages, the learner may have a limited understanding, the expert offersdirections or modeling, and the learner’s responses are acquiescent or imitative.Only gradually does the learner understand the way in which the parts of theactivity relate to one another or understand the meaning of the performance. Whensome conception of the overall performance has been acquired, further assistancecan be given by questions, feedback, and further cognitive structuring. The expertassists by grading tasks and by structuring tasks into sub-goals and sub-sub-goalsin a similar fashion to task analysis (Anderson & Faust, 1973; Gagne, 1985). Aprofound knowledge of subject matter is required of teachers who seek to assistperformance. Without such knowledge, teachers cannot quickly reformulate thegoals of the interaction; they cannot map the learner’s conception of the task goalonto the superordinate knowledge structures of the academic discipline that isbeing transmitted.

During stage one, there is a steady decline plane of teacher responsibilityfor task performance and a reciprocal increase in the learner’s proportion ofresponsibility. This is described as the handover principle (Bruner, 1983, p. 60).The developmental task of stage one is to transit from other-regulation to self-regulation. The teacher’s task is to accurately tailor assistance to the learner bybeing responsive to the learner’s effort and understanding of the task goal. The taskof stage one is accomplished when the responsibility for tailoring the assistance,tailoring the transfer and performing the task itself has been effectively handedover to the learner.

Stage two is where performance is assisted by itself. In stage two, the learnercarries out a task without assistance from others. However, this does not meanthat the performance is fully developed or automatized. It contains the next stagein passing of control or assistance from the expert to the apprentice. What wasguided by others is now beginning to be guided and directed by the learner. At the


microgenetic level, adults consistently talk to themselves, and assist themselves inall ways possible.

Stage three is where performance is developed and automatized. Once allevidence of self-regulation has vanished, the learner has emerged from the zoneof proximal development (ZPD) into the developmental stage for the task. The taskexecution is smooth and integrated. It has been internalized and ‘automatized’.Assistance from the expert or the self is no longer needed. Assistance at this stagecould be disruptive. It is in this condition that instructions from others are disruptiveand irritating; it is at this stage that self-consciousness may be detrimental to thesmooth integration of all task components. Performance is no longer developing; ithas developed.

Stage four is where de-automatization of performance leads to recursion backthrough the ZPD. The lifelong learning by an individual is made up of these sameregulated ZPD sequences, from other-assistance to self-assistance, recurring overand over again for the development of new capacities. For every individual, atany point in time, there will be a mix of other-regulation, self-regulation, andautomatized processes. Even the competent expert can profit from regulation forenhancement and maintenance of performance. Indeed, enhancement, improve-ment and maintenance of performance provide a recurrent cycle of self-assistanceto other-assistance. De-automatization and recursion occur so regularly that theyconstitute a stage four of the normal developmental process. What one formerlycould do, one can no longer do. After de-automatization, for whatever reason(environmental changes, stress, major upheavals, trauma), if capacity is to berestored, then the developmental process must become recursive.

The first line of retreat is to the immediately prior self-regulating phase. Recur-ring to the point in the zone where the learner ‘hears the voice of the teacher’may be an effective self-control technique. However, in some cases no form ofself-regulation may be adequate to restore capacity, and the restitution of other-regulation is often required. In this instance, the goal is to re-proceed throughassisted performance to self-regulation and to exit the ZPD again into a newautomatization.

Assisted Performance and Teaching within the ZPD

There are various means of assisted performance (modeling, contingency manage-ment, feeding-back, instructing, questioning, and cognitive structuring). Tharp andGallimore (1988) provided a detailed account of these approaches to coaching.Linguistic means of assistance (instructing, questioning and cognitive structuring)often dominates teaching. A good mix of the three types of verbal assistanceproduces a lively and cooperative teacher-learner interaction. However, that whichis modeled is internalized and represented by the learner as an image, a paradigm-icon, for self-guidance. Contingency management is a means of assisting perfor-mance by which rewards and punishments are arranged to follow on behavior,


depending on whether or not the behavior is desired. In effective teaching,contingency management is focused overwhelmingly on positive behavior andpositive rewards. Although contingency management is a powerful means ofassisting performance, it cannot be used to originate new behaviors. Develop-mental advances are originated by other means of assistance; modeling, instructing,cognitive structuring and questioning.

In self-regulation, providing for feedback is the most common and singlemost effective means of self-assistance (Watson & Tharp, 1988). In educationalprograms, feedback regarding performance is vital to every participant. Feedbackin any system does not refer to information traveling along an unconnected line.It implies the existence of a closed loop; that is, for information to be consideredfeedback, it must be fed to a system that has a standard, as well as a mechanism forcomparing a performance to the standard. Simply providing performance informa-tion is insufficient; there will be no performance assistance unless the informationprovided is compared to some standard. The expert teacher must be able to selectand apply each form of assistance as required by the learning situation. This isbecause the responsiveness to the ZPD requires individualization according to theexigencies of the moment and the movement through the ZPD.

The amount and type of assistance will vary with the experience and levelof performance of the teacher. However, it should be noted that the skillfulteacher/expert might always benefit from new competencies or improved perfor-mance in a particular domain. Consequently, even expert teachers have an inter-dependence on other experts who have a different/complimentary skill profile.The teacher has a ZPD for teaching skills, which requires assistance as in anyother learning process. Consequently, an effective institution will assure assistanceis provided to all of its teachers and experts, whatever their level of expertise.Teaching as assistance is an extremely complex skill that requires constant decisionmaking, categorizing, structuring and all manner of cognitive operations (Tharp& Gallimore, 1988). Such a process may include the use of self-examination ofvideotapes, floor training, workshops and courses and the use of consultants. Adetailed account of the processes and stages of the development of higher-orderteaching skills can be obtained by reading Tharp and Gallimore (1988). To be aneffective consultant, the individual must be an expert in the skills and knowledgethat is being taught in addition to being expert in teaching. Tharp and Gallimore(1988) describe this concept as integrating the two domains of knowledge.

The framework for learning and teaching within the ZPD includes modelsfor understanding the social and organizational components of learning, such asactivity setting(s) (the context in which teaching occurs), and the triadic model ofassisted performance. A detailed account of these concepts is beyond the scope ofthis manuscript, but a number of accounts are available within the educational liter-ature (Rogoff, 1982; Weisner, 1984; Fischer & Bullock, 1984; Tharp & Gallimore,1988).


Discussion

From a review of the educational literature on expertise, it is clear that conceptsof expertise may be important in planning both the education of healthcare profes-sionals and understanding aspects of service delivery. When the three models oflearning/teaching are compared, it is evident that each of them has both strengthsand weaknesses with regard to providing a framework for how expertise can bedeveloped. Within this discussion, we propose to initially highlight the benefitsand deficiencies of each model, and then draw together the strengths from eachmodel to assist in providing a clearer educational framework for the developmentof expertise.

The Nursing model for experiential learning containing five levels (novice,advanced beginner, competence, proficient, expert), is the only one of the three thatwe have reviewed which specifically includes expertise as a level of performance(Benner et al., 1996a–d). The first four of these levels contain stages of learning thatare similar to the three phases of psychomotor skill acquisition (cognitive, integ-rative/associative, autonomous), and the first three stages of the ZPD. Furthermore,a framework is provided for the development of emotional involvement, perceptionand intuition (pattern recognition).

However, within the above model of trial and error learning, there are alsoa number of educational deficiencies. First, Benner et al. (1996a–d) apply theirframework to nursing practice as a whole (sets of skills), rather than to the processof acquiring a specific skill as is outlined in both the psychomotor literature andthe ZPD. They describe how nurses reach each of these five levels of expertise withregard to their entire practice, rather than achieving differing levels of expertiseacross the spectrum of skills required to practice as a nurse. Consequently, it is notclear from their account that nurses would usually acquire expertise in a specificarea such as neurological or geriatric nursing, rather than expertise across the wholerange of possible areas of nursing.

Within this model of experiential learning there appears to be varying levelsof learner supervision (coaching), the authors do not describe how the principlesof teaching are integrated into such an approach to skill acquisition, and thereis no discussion of the principal of hand-over of responsibility between teacherand learner (ultimate recognition of the learner as a colleague). However, the needfor preceptors/mentoring/coaching is identified, and within this model experts areavailable to learners. Consequently, Benner et al. (1996a–d) describe a model forknowledge and skill acquisition where there is only partial supervision.

There is no acknowledgement of the role of the teacher in identifying whichtasks may require close supervision. In knowledge-rich/complex areas, the needfor help and potential pitfalls may not always be obvious to the learner, and theexpert has a major role in tailoring tasks to the level of competence of the learner.In some domains such as healthcare or training airline pilots, trial and error learningmay not be appropriate due to the significant potential consequences if errors occurwhilst learners are not supervised. Furthermore, there are additional risks of unsu-


pervised learning such as the development of undesirable patterns of practice thatmay be difficult to correct, and the risk of progressively poorer execution of skillsassociated with practice by habit. Consequently, the experiential model of learningpresented by Benner et al. (1996a–d), is the least well developed educationally ofthe three models of learning, with poor definition and integration of pedagogicalexpertise into the phases of learning. Finally, the description of expertise couldbe augmented by more recent concepts of expertise (Bransford et al., 1999), andthe importance of duel expertise in the subject matter that is being taught andapproaches to teaching is not identified (Tharp & Gallimore, 1988).

The psychomotor model of surgical skill acquisition gives a clear outline ofthe stages of learning up to a point at which performance becomes smooth andautomatic. However, the transition from competence to expertise is not outlined,and concepts of expertise have not been integrated into this model of learning.From the psychomotor model it can be understood that a learner will go througha process from the cognitive stage to the autonomous stage for each skill that islearned. Consequently, a practitioner will develop a “kit-bag” of skills that they canperform well, and (provided these that skills are maintained), that may ultimatelybe included within their area of expertise. Clearly, from this model of learningit can be seen that expertise is ultimately developed only in those areas whereappropriate learning has taken place. In the surgical literature on psychomotor skillacquisition, there is no formal recognition that under certain circumstances, thecapacity to perform skill(s) can deteriorate or be lost, and that there is a process forrelearning as is outlined in phase four of the ZPD (Tharp & Gallimore, 1988).

We previously noted that Fitts and Posner (1967) believed that continued useof cognitive processes during the performance of autonomous psychomotor skillsinhibits performance. We would like to emphasize that some skills such as surgicaloperations cannot (should not), be performed without cognition. For example,whilst components of skills may be automated such as tying a knot whilst suturing,cognition is required to plan the overall approach to a surgical procedure, andto know how and when to apply various techniques and skills. Cognition is alsorequired to deal with unexpected events and variation in circumstances. Thisimportant point can be further clarified. Metacognitive monitoring of ongoingactions is the capacity to remain aware of the whole situation, to monitor eventsas they occur, to reflect on alternative possibilities should a decision need to bemade, and to maintain the “mental space” to reflect on processes that are happeningskillfully/automatically (Garofalo, 1986). This kind of monitoring is a feature ofexpertise, and is made possible by not being required to direct limited cognitiveresources to more mundane (automated) aspects of a task. The need to cognitivelyplan and process routine aspects of a task is detrimental to performance. However,metacognitive monitoring is an important component of surgical expertise. Thus,it is clear that models used to understand learning/teaching of psychomotor skillswould benefit from the inclusion of concepts of expertise.


Table II. Phases for acquiring expertise

Phase of acquiring Experiential Psychomotor skill Phase of ZPDexpertise learning acquisition

One Novice Cognitive Outside regulation

Two Advanced beginner Integrative/associative Self-regulation

Three Competent/proficient Autonomous Automatisation

Four Expert

Akin to phase four of the ZPD, under some circumstances a learner or expert may become lessproficient at performing skill(s), drop to a lower phase of learning, and then re-ascend up the“ladder” of learning levels.

When comparing the model for learning psychomotor surgical skills to theeducational model of assisted performance within the ZPD, pedagogical expertiseis less well integrated into the psychomotor model. The psychomotor literaturegives a clear account of the importance of feedback (including “feel for the task”),cognitive structuring and motivation. However, modeling is an essential componentof psychomotor skill acquisition. Such modeling is likely to take place on a regularbasis, however, it’s importance is not widely stressed within the surgical literature(Cauraugh et al., 1999). Consequently, modeling may not always take place byan expert, and optimal model(s) for performing skills may not be internalized.Furthermore, the literature does not emphasize the importance of verbal means ofassistance, and the importance of varying approaches to assistance as part of goodteaching. The literature on psychomotor skill acquisition would benefit from thefurther integration of concepts regarding teaching expertise (Tharp & Gallimore,1988).

Of the three models, the Zone of Proximal Development contains the bestintegration of phases of learning with teaching expertise (the two domains)and concepts of teacher-learner interaction(s) (including the hand-over principal,and social and organizational approaches to learning). There is also appropriateemphasis upon how teaching skills can be acquired. Furthermore, as with thepsychomotor literature, the ZPD contains a clear outline of how individual skillscan be acquired. The ZPD is the only model to clearly identify that under certaincircumstances, the performance of skills may deteriorate, and also to outlineprocesses by which these skills may be regained (recursion through a lower levelwithin the ZPD). However, the literature on the ZPD does not outline specificallyhow a learner transits from phase three (autonomous performance) to expertise, norclearly outline concepts of expertise.

Each of these three educational models contains information that is important tothe process of acquiring expertise. We believe that an integration of concepts fromeach of these models as outlined in Table II, may produce a clearer frameworkof the educational requirements for achieving expertise. First, a clear explanationof concepts of expertise is important as was outlined earlier in this manuscript.


Second, there are three phases for acquiring any skill as outlined in both thepsychomotor literature and accounts of the ZPD. Third, a learner acquires a “kit-bag” (limited range) of skills that they are competent at performing. Fourth,there is a fourth phase of learning (acquisition of expertise) beyond autonomousperformance of skills.

Fifth, it is important to recognize that under certain circumstances the perfor-mance of skills may deteriorate or be lost (phase four of the ZPD), and withappropriate assistance (self or other) there can be recursion through a less advancedphase of learning to the original level of expertise. Sixth, the inclusion of awell developed teaching framework as outlined within accounts of the ZPD isextremely important, including concepts of how teaching expertise is acquired andexecuted (the concept of expertise in “two domains”), and social and organizationalapproaches to learning. As each learner/practitioner may be at different phases oflearning for some of the skills that they require to practice, new skills may have tobe learned, the performance of some skills may deteriorate or be lost, and supportmay be required to progress from phase three of the ZPD to expertise, educationalsupport should continue for all learners and practitioners including experts. Thisis of major importance for how continuing professional education is provided andhow environments should be structured where everyday healthcare practice takesplace.

A number of implications for healthcare practice and education stem from theproposed model. The scope of practice and planned educational outcomes relatedto a given area of knowledge/practice may vary depending upon the type of prac-titioner. For example, in the medical domain a family physician might be expectedto be cognitively aware of different types of fallopian tube surgery (phase one).General gynaecologists may have differing levels of performance depending upontheir type of practice, and may be at either phase two or phase three for complexfallopian tube surgery. However, a subspecialist reproductive endocrinologist willbe at phase four for such surgery (expert), being able to both compare and contrastdiffering approaches to care for a given patient, based upon subtle nuances (suchas during the choice between surgery and in-vitro fertilization), and deliver eachtype of care expertly. In the nursing domain, upon graduation a general nurse willbe cognitively aware (phase one) of different approaches to urinary incontinence,and a nurse working exclusively with incontinence patients may be at either phasetwo or three for most forms of nursing management. However, an advanced nursepractitioner would be expected to be at phase four (expert).

In the cardiology domain, most types of medical practitioner should be cognit-ively aware of the importance of detecting hypertension, and how cardiac diseasemay impact upon care that they provide (phase one). Furthermore, they should haveprocedural knowledge/skills for how to treat some emergency situations, such asacute left ventricular failure or a cardiac arrest (phase two or phase three for asmall number of situations). Family physicians should be acquainted with a rangeof cardiac conditions (phase one), be able to initiate or modify therapy for some


conditions such as mild hypertension, and know both how to identify and when torefer complex cases (phase two or phase three for a limited range of situations).General internists will require both an in depth knowledge and skills to managea broad range of cardiac conditions, and how these interplay with other types ofmedical conditions (phase three for a broad range of cardiac conditions). Cardi-ologists are expert (phase four) at managing both simple and complex cardiacconditions, and able to undertake complex investigations and interventions suchas cardiac catheterisation.

With regard to pain management, most physicians and nurses should be awareof a range of options for pain management (phase one), able to either prescribeor administer simple analgesics, and able to recognise when acute or chronicpain requires assessment by a professional with a higher level of expertise. Somesubgroups of health professionals should have attained phase three for managingcertain kinds of pain. Examples include midwives administering analgesics towomen in labour (including being able to recognise when an epidural would bebeneficial), palliative care physicians or nurse practitioners providing pain relief toterminally ill patients, and anaesthetists managing post operative pain. However,members of a pain control team will be expert (phase four) at managing a broadrange of types of pain including complex cases, and able to provide expert adviceand interventions within a broad range of healthcare domains.

These patterns of practice will have a significant impact upon the design ofeducational programs for each type of practitioner, drawing upon the educa-tional input required to achieve the desired level of performance. Furthermore,for subspecialists, advanced nurse practitioners and other types healthcare prac-titioners who perform at an equivalent level within their own domain, it is probablethat they should restrict their area of practice in order to both achieve and maintainphase four (expertise).

Some graduating practitioners may not have achieved phase three for all of theskills/knowledge that would be required to practice competently in their chosenarea/type of practice. Consequently, appropriate support will be required for themto reach phases three and four. New procedures and knowledge are constantly beingintroduced. Furthermore, under certain circumstances practitioners may drop to alower level (phase) of performance. Therefore, appropriate educational supportsare required in locations where practitioners both undertake their everyday prac-tice, and refine nascent skills. In view of the educational skills required to supportprogression through the four phases (combined teaching expertise and practitionerexpertise), there is a strong argument for supporting the development of clin-ical teaching consultants who would become an integral part of both continuingeducation and service delivery.

A number of questions arise from this review and analysis of expertise.Firstly, in the healthcare domain, can we reliably identify experts in order tovalidate models of expertise, and undertake further research into both performancecharacteristics and educational processes? Ericsson and Smith (1991) suggested


that expert performance must be studied with individuals who can reliably andrepeatedly demonstrate superior performance. There is some evidence from patientoutcome studies that there is a broad range of standard of performance for medicalspecialists in everyday practice (Dunphy et al., 1996; Human Fertilisation andEmbryo Authority, 2002). Furthermore, in the surgical domain there may be ahigh incidence of basic errors in surgical technique for newly qualified specialists(Kopta, 1971), there may be a long learning curve for some surgical procedures(Boeckx et al., 1985; Dunphy et al., 1997), and without attention to techniquestandards of performance may deteriorate with time, perhaps linked to “practiceby habit” without appropriate quality assurance/feedback (Wingard & Williamson,1973; Seki, 1987). Therefore, we may not be able to assume that a specialist in anarea of healthcare is an expert simply because they have practiced in that area for acertain amount of time, or they have completed either an educational or certificationprocess.

In non-healthcare domains such as competitive sports (e.g., tennis) or competi-tive chess, only a proportion of players might achieve the status of expert, suchas those qualifying for Wimbledon (tennis) or acquiring the title of Master orGrand Master (chess). Consequently, although healthcare is not usually perceivedas a competitive environment, can we identify experts for the purposes of researchbased upon the quality of performance and/or the standard of patient outcomes?

Secondly, does expertise in an area of healthcare reflect completion of a rigorouseducational process such as subspecialist training, or voluntary restriction of prac-tice for a significant period of time to an area of special interest or demonstratedaptitude? This is an important question, as a number of aspects of healthcare arestructured around subspecialisation. In certain situations, a subspecialist approachwould appear logical, however, further research may be required to determineeducational approaches that will reliably produce experts in a given healthcarefield.

Thirdly, do models for the acquisition of expertise reflect a neurological and/orphysiological process by which expertise is acquired? Studies of psychomotor skillacquisition using magnetic resonance imaging (MRI) suggest that learning is asso-ciated with rapid changes in certain areas of the brain over the course of days(perhaps consistent with phase one of expertise), followed by a slowly evolvingreorganization within other areas (perhaps a progression through phase two tophase three) over the course of weeks (Muller et al., 2002; Ungerleider et al., 2002).Furthermore, recent evidence using MRI suggests that intellectual and perceptual-motor skills are acquired in fundamentally similar ways, and that brain sitessubserving thought processes and perceptual-motor processes are not as distinctas once thought (Rosenbaum et al., 2001). These findings present some evidencethat supports a three-phase process for acquiring both procedural knowledge andpsychomotor skills. More research is required to determine if there are further neur-ological changes associated with the acquisition of expertise, that would present


physiological evidence for processes that occur between the acquisition of skill(s)(phase three) and the development of expertise (phase four).

Lastly, will lessons learned from such research lead to the validation of orimprovement(s) to educational processes, improved patient outcomes, and/or ahigher proportion of the healthcare workforce achieving expertise in their chosendomain? Clearly, more research is required to validate model(s) of expertiseincluding studies that encompass both patient outcomes and educational outcomes.

Acknowledgments

We grateful to Dr Karen Mann, of the Division of Medical Education, DalhousieUniversity, Canada, for her advice and support.

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In Pursuit of Expertise. Toward an Educational Model for Expertise Development

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