Expertise in nursing practice : caring, clinical judgment - Springer ...
Expertise in nursing practice : caring, clinical judgment - Springer ...
Expertise in nursing practice : caring, clinical judgment - Springer ...
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6 <strong>Expertise</strong> <strong>in</strong> Nurs<strong>in</strong>g Practice<br />
The evidence concern<strong>in</strong>g INTERNIST-1iseven more detailed. In<br />
fact, accord<strong>in</strong>g to The New England Journal of Medic<strong>in</strong>e, which published<br />
anevaluation of the program, “the systematic evaluation of the<br />
model’s performance is virtually unique <strong>in</strong> the field of medical applications<br />
of artificial <strong>in</strong>telligence” (Miller, Harry, Pople, &Myers, 1982).<br />
Theevaluators found that “theexperienced cl<strong>in</strong>ician is vastly superiorto<br />
INTERNIST-1<strong>in</strong>the ability to consider the relative severity and <strong>in</strong>dependence<br />
of the different manifestations of disease and to understand<br />
the temporal evolution of the disease process (p. 476).<br />
Dr. G. O. Barnett (1982), <strong>in</strong> his editorial comment ontheevaluation,<br />
wisely concludes:<br />
Perhaps the most excit<strong>in</strong>g experimental evaluation of INTERNIST-1would<br />
be the demonstration that a productive collaboration ispossible between<br />
man and computer—that cl<strong>in</strong>ical diagnosis <strong>in</strong> real situations can be improved<br />
bycomb<strong>in</strong><strong>in</strong>g the medical <strong>judgment</strong> of the cl<strong>in</strong>ician with the statistical<br />
and computational power of a computer model and a large base of<br />
storedmedical <strong>in</strong>formation. (p. 5)<br />
Nurses who have to turn the conclusions of theory <strong>in</strong>to treatment<br />
have to supply this cl<strong>in</strong>ical <strong>judgment</strong>. As Patricia Benner (1984a) po<strong>in</strong>ts<br />
out, cl<strong>in</strong>ical <strong>judgment</strong>s, such as ma<strong>in</strong>ta<strong>in</strong><strong>in</strong>g a patient with<strong>in</strong> specified<br />
physiological parameters with medications, requires experience-based<br />
<strong>in</strong>tuition.<br />
The Platonic rationalist tradition, however, would support theexpert<br />
systems builders. There must be atheory underly<strong>in</strong>g all expertise, they<br />
claim, so one should be able to f<strong>in</strong>d and articulate the pr<strong>in</strong>ciples underly<strong>in</strong>g<br />
even diagnosis and treatment. We will formulate these pr<strong>in</strong>ciples,<br />
program them, teachthem, and eventest for expertise by exam<strong>in</strong><strong>in</strong>g students<br />
on how well they know them. But Aristotle’s argument that one<br />
must at some po<strong>in</strong>t use <strong>judgment</strong> to decide how to apply the rules, plus<br />
the general failure ofexpert systems us<strong>in</strong>g rules without <strong>judgment</strong>, suggests<br />
that even a discipl<strong>in</strong>e that has a theory must ultimately rely on<br />
practical <strong>in</strong>tuition when itneeds to touch reality.<br />
To understand the role of<strong>in</strong>tuition, even <strong>in</strong>atheoretical discipl<strong>in</strong>e<br />
like medic<strong>in</strong>e, and the implication of this relationship for nurs<strong>in</strong>g, a fresh<br />
look must be takenatthe def<strong>in</strong>ition of skill and what theexpert acquires<br />
whenhe achieves expertise.We must be preparedto abandonthe Greek<br />
view that a beg<strong>in</strong>ner starts with specific cases and as he becomes more<br />
proficient abstracts and <strong>in</strong>teriorizesmore and more sophisticated rules. It