Aiming for excellence as an applied psychologist

Narinder Kapur and Barbara A. Wilson outline 15 ‘pillars’ to support you.

Excellence as a scientific concept has seldom been the subject of academic scrutiny. This article describes a framework for excellence that can be related to areas of applied psychology. Fifteen ‘pillars of excellence’ are outlined that may help guide professional psychologists in activities such as appraisal and continuing professional development.

The Shorter Oxford Dictionary (2002) defines excellence as ‘the possession of good qualities or abilities to an eminent or unusual degree’. High quality in most forms of human endeavour depends on five main factors:
I    Human excellence (the subject of this article) comprising greatly enhanced skills, knowledge and experience in particular domains valued by society;
I    Procedures and systems in place that encourage excellence and discourage bad practice;
I    Exemplary standards of materials, resources and environments providing a context where high-quality performance can flourish;
I    The existence of a range of strong connections to other people of excellence and other centres of excellence;
I    Equipment that both enhances effective and efficient performance,
and whose design makes it unlikely that major malfunction or operator error will occur.

The purpose of this article is to consider the concept of human excellence in professional disciplines of applied psychology. This article is, in part, based on an earlier paper that considered excellence from the standpoint of clinical medicine (Kapur, 2009).

Technical pillars
These pillars cover how capable you are at your job: evidence-based thinking and practice, professional and peer accreditation, decision-support systems, effectiveness and efficiency, and learning and risk management.

We live in an era of accountability when psychologists, among others, are expected to show evidence of the efficacy of their practice (Moran & Malott, 2004). Published data in peer-reviewed journals are just one way of seeking sources for evidence-based practice. Other ways include surveys, audit and the systematic collection of personally reviewed cases.

All can be harnessed to help in evaluating applied psychological practice. In addition to evidence-based psychology – a necessary but not sufficient condition of good practice (Kazdin, 2008; Lilienfeld & O’Donohue, 2006) – judgement, common sense, and an approach reflecting the priorities of the recipients of psychological services are required (Kaptein et al., 2009). As Smith (2007) reminds us, the effectiveness of evidence-based practice will only be as good as the evidence on which it is based. The evidence itself should also be subject to stringent analysis. Whatever the evidence, the benefits may only be translated into practice in the hands of an accomplished and capable psychologist.

Who decides whether a psychologist is accomplished and capable? Although peer appraisals are the norm in academic, educational and research settings, they are, perhaps less common in applied psychology, at least in the UK. Winstone and Gervis (2006) found that sports psychologists relied more on themselves and informal networks to manage their practice than on formal supervision or review. In some countries it is customary to have external peer reviews to improve clinical practice and ensure high standards across healthcare providers (van Weert, 2004). Peer review by colleagues is not a threat, but a valuable weapon in our search for optimal performance. Like other professions, such as medico-legal practice (Lauer, 2002), we can benefit from observation by peers, critical peer review of our work and visits to experts in the field.

We should also make use of decision-support systems. These include commercial search engines such as Google, dedicated medical databases, database-support systems, use of health information technology and guideline-based reminder systems (Graber & Mathew, 2008). Decision-support systems apply to diagnosis, treatment and even to ethical decisions relating to care of patients with dementia. Bolmsjö et al. (2008) provide a summary of resource-supported treatments that can be used when clinical psychologists are unsure about which treatment to select, when treatment does not seem to be working, when they need to justify their approach to others, or when they have insufficient time to review recent research.

How should we judge the efficacy or otherwise of psychological services? This task is high on today’s agenda. We need to include outcome measures that reflect the hopes and needs of the recipients of the services, their degree of stress, the well-being of family members and satisfaction with services received (Hine et al., 2008). Patient-reported outcome measures (PROMs) can be useful measures of the effectiveness of certain treatments (Brown et al., 2007). The European Quality of Life (EuroQol) group (first described by Williams, 1990) has produced a standardised instrument, the ED-5D, for measuring healthcare outcome.

Personal pillars
How good a person are you? One way to consider this is by looking at interpersonal skills, collaboration and leadership, resilience and stress management, user involvement, and moral principles.

Interpersonal skills include the ability to interact well with clients and colleagues, and to handle social and emotional aspects of human communication. Errors can result from misunderstandings between psychologists and those they are working with and may lead to the administration of inappropriate measures, or to poor compliance with treatment. We need to ensure shared understanding (Butler, 1998; Wilson et al., 2009) and, if working in teams, should encompass the philosophy and vision of team members, as well as their explicit values and goals and their understanding of research and theory. Knowledge and experience should be shared with other professionals and clients or patients.

Team working and leadership are important constructs in applied psychology (Riggio, 2008). Team working should ensure that mutual understanding and good communication occurs between team members and strong, effective leadership is provided by the team leader, with adherence to key principles and constancy of purpose. Good leadership entails skills in directing, supporting and delegating, and being a role model for enunciating and persevering with key principles, regardless of obstacles and difficulties (Gardner, 1996).

The ability to deal with such obstacles – to persevere despite stress, and manage stress constructively – are important qualities for applied psychologists.

Howard (2008) discusses the contribution of positive psychology to the management of stress; while, from the field of medicine, Jensen et al. (2008) listed a number of key features of resilience – the ability to prioritise work activities; having well-structured work routines; having peer-support mechanisms in place; ensuring good work–life balance; being aware and reflective of one’s strengths and limitations; having core values; a degree of optimism; an altruistic frame of mind; maintaining a sense of humour; and an element of forgiveness and acceptance of oneself and others.

This acceptance of others extends to involving them. In applied psychology, we deal with the clients we work with and, sometimes, their families. We may also deal with other bodies, such as schools, hospitals and sports clinics. In the UK there have been moves to promote greater involvement of clients in service provision. For example in health care there is an expert patients programme (www.expertpatients.nhs.uk) and the NHS Centre for Involvement (www.nhscentreforinvolvement.nhs.uk). The user involvement pillar of excellence simply stipulates that we ask those who directly or indirectly use a service what they think of the service provided (Weigelt et al., 2004). Clients should be given opportunities to comment on the care or service received. The idea of ‘360 degree feedback’, common in some areas of industry, but less common in applied psychology, tries to espouse similar concepts to those that are incorporated within user-feedback (Reed et al., 2008; Wood et al., 2006). An issue remaining open for discussion and research is the extent to which such feedback should be linked to specific rewards or even to pay (Rynes et al., 2005).

Finally, there are a person’s moral principles. In his commentary on professionalism in medicine, Hafferty (2006) proclaimed that ‘medicine is a moral community, the practice of medicine a moral undertaking, and professionalism a moral commitment’ (p.2152). This is also true for psychology, and Cermak (2002) has outlined how academic departments of psychology should be committed to helping the communities in which they are located.

In the goal-driven and competitive environment of many settings, it is easy to forgo moral principles, such as the key Gandhian principles of truth and compassion. Such principles need to be strictly followed in dealings with patients, clients and colleagues, even if this involves self-sacrifice, personal distress or loss of self-esteem. Opportunities for morally laudable professional activity may arise around or after retirement, and healthcare professionals in the developed world should be encouraged to grasp opportunities to help those in developing countries (Ausman, 2007).

In science it has been shown that preoccupation with money results in
self-centred behaviour (Vohs et al., 2006), and this phenomenon may transfer unconsciously to other environments. Currently, there is, perhaps, more pressure to consider goals and targets, rather than the means used to attain them, leading to a temptation to forgo high moral standards. Having an ‘ethical compass’ and key values is critical in order to survive the challenges of modern healthcare environments (Gardner, 2007).

Future pillars
The final set of pillars covers what improvements you will leave behind. This includes policy and succession planning, teaching and training, innovation, research and publications, and income-resource generation.

Forward policy planning may not be the immediate concern of more junior psychologists, but it is a skill that will be in demand in the later stages of their careers. There is an increasing realisation of the importance of predicting developments that will impact on their practice, and of succession planning (Dolan, 2005) to prevent major unexpected gaps in a service when someone retires or becomes incapacitated. Succession planning incorporates a variety of activities, from teaching juniors about the technical and managerial skills involved in performing tasks, to writing books and papers that convey lessons learned in one’s career.

We have legal wills between parents and children, but seldom have professional or academic wills to deal with client care and financial issues (DeAngelis, 2008), and bequeath the fruits of one’s knowledge and experience to younger colleagues. This could include reprints, books, slides and videos.

Excellence in imparting knowledge may be evident in specific outcomes, whether they be successful professionals or peer-reviewed journal publications. A good teacher not only imparts key pearls of wisdom and encourages self-reflection, but also acts as an exemplary role-model and has non-cognitive qualities such as the ability to inspire students in the learning process (Sutkin et al., 2008). In this age of globalisation, teaching and training should cross national boundaries. Many units in the West have informal links with those in developing countries. Exchange of staff and transfer of surplus equipment may be in place. An important component of knowledge-sharing often ignored is educating the public about psychological issues. The general public makes increasing use of web-based resources to inform themselves about psychological issues, and perhaps on occasions are overwhelmed by information of varying degrees of reliability. It is important, therefore, that both psychologists and governments try to help the public discern the valuable from the worthless or the misleading. 

The next pillar is innovation, reflecting the fact that progress comes through the development of new knowledge, new procedures and new treatments (Greener, 2005). How to nurture and reward staff who show creativity, and ensure high standards of psychological expertise, remains a challenge. Joint academic-applied appointments remain a defence against the decline of creativity but there needs to be a culture where research and innovation are welcomed and rewarded. In the UK healthcare field, the NHS Institute for Improvement and Innovation (www.institute.nhs.uk) has been specifically established to improve health care by helping to introduce new ways of working, new technologies and high-quality leadership.

Research is expected from those with academic-applied psychology appointments, but many great discoveries were based on the ability to make acute and astute observations, and to draw psychologically relevant conclusions from these. The importance of the hippocampus for memory was discovered through observations of one patient, H.M., operated on for the relief of epilepsy (Scoville & Milner, 1957). ‘Good research does not always require a budget of hundreds of thousands of dollars, batteries of computers and an electron microscope; the essential requirement is a question that can be answered positively or negatively by carrying out a series of measurements and making the correct mathematical or statistical analysis’ (Rutherford, 1986, pp.164–5). Research skills and competencies should be rewarded in psychology, especially where these have been acquired through an individual’s initiative. Observations and discoveries are of little value unless they are written up for others and for future generations. Publishing papers and books is a skill that needs to be acquired and encouraged, and should form a key component of any clinical excellence framework.

The final pillar – the ability to generate income and attract resources, such as grants and collaboration with industry – has seldom been perceived as a distinctive skill for applied psychologists, but could be important in today’s age of restricted funds. Skills and success in generating income and resources need to be acknowledged, rewarded, set in the context of ethical principles, and be in the best interests of client care and scientific progress (Frangioni, 2008).

Conclusions
The central tenet of this article is that ‘human excellence’ is a multifactorial entity, and the range of relevant factors can be collapsed into three critical domains relating to technical proficiency, personal skills and future legacy. An important feature of the current proposal is its inclusion of ‘personal’ pillars, an area that has traditionally been neglected in appraisal and reward systems (Larson, 2007). 

The pillars of excellence outlined in this article should help to provide a stimulus and a distinctive framework that encourages  a critical attitude and a new ethics in applied psychology. This schematic framework may be useful as a personal aide-memoire for psychologists in their professional activities, and may additionally serve as a pragmatic template for both individual and organisational appraisal, accreditation, revalidation and reward systems. The framework may also be useful as a teaching tool for conveying principles relating to quality of care, not only to psychologists but also to a range of professionals contacted by psychologists.

A critical, further step would be to gather evidence derived from a checklist or appraisal format that was based on the framework described in this article, and then to consider not only some form of validation study, but also how easy and acceptable it was to implement evaluations using this framework in standard settings. In this way, we may be able to lay the foundations for a ‘science of professional excellence’. (cf. Gardner et al., 2001).

- Narinder Kapur Department of Neuropsychology, Addenbrooke’s Hospital, and Department of Psychology, University of [email protected]

- Barbara Wilson Medical Research Council Cognition and Brain Sciences Unit, Cambridge, and the Oliver Zangwill Centre, Ely

References
Ausman, J. (2007). ‘What will you do with the rest of your life?’ Surgical Neurology, 68, 112–113.
Bolmsjö, I.A., Edberg, A-K. & Sandman, L. (2006). Everyday ethical problems in dementia care: A teleological model. Nursing Ethics, 13, 340–359.
Brown, J., Jamieson, L., Lewsey, J. et al. (2007). Patient reported outcome measures (PROMS) in elective surgery. Report to the UK Department of Health.
Butler, G. (1998). Clinical formulation. In A. Bellack & M. Hersen (Eds.) Comprehensive clinical psychology. Oxford: Pergamon Press.
Cermak, L. (2002). Amnesia for the past causes deficits in prospective planning (pp.297–304). In A. Stringer, E. Cooley & A-L. Christensen (Eds.). Pathways to prominence in psychology: Reflections of twentieth-century pioneers. New York: Psychology Press.
DeAngelis, T. (2008). Prepare for the unexpected. Monitor on Psychology, 39, 51–52.
Dolan, T. (2005). Increasing succession planning. Healthcare Executive, 20, 6.
Frangioni, J. (2008). The impact of greed on academic medicine and patient care. Nature Biotechnology, 26, 503–507.
Gardner, H. (1996). Leading minds: An anatomy of leadership. New York: Basic Books.
Gardner, H. (2007). The ethical mind. A conversation with psychologist Howard Gardner. Harvard Business Review, 85, 51–56.
Gardner, H., Csikszentmihalyi, M., & Damon, W. (2001). Good work: When excellence and ethics meet. New York: Basic Books.
Graber, M. & Mathew, A. (2008). Performance of a web-based clinical diagnosis support system for internists. Journal of General Internal Medicine, 23, Supplement 1, 37–40.
Greener, M. (2005). Engendering creativity in the biomedical sciences. EMBO Reports, 6, 402–404.
Grout, J. (2007). Mistake-proofing the design of health care processes. Rockville, MD: Agency for Healthcare Research and Quality.
Hafferty, F.W. (2006). Professionalism – The next wave. New England Journal of Medicine, 355, 2151–2152.
Hine, C.E., Howell, H.B. & Yonkers, K.A. (2008). Integration of medical and psychological treatment within a primary health care setting. Social Work in Health Care, 47, 122–134.
Howard, F. (2008). Managing stress or enhancing well-being? Australian Psychologist, 43, 105–113.
Jensen, P., Trollope-Kumar, K., Waters, H. & Everson, J. (2008). Building physician resilience. Canadian Family Physician, 54, 722–729.
Johnson, J. (2008). Using research-supported group treatments. Journal of Clinical Psychology, 64, 1206–1224.
Kaptein, A.A., Scharloo, M., Fischer, M.J. et al. (2009). 50 years of psychological research on patients with COPD – Road to ruin or highway to heaven? Respiratory Medicine, 103, 3–11.
Kapur, N. (2009). On the pursuit of clinical excellence. Clinical Governance: An International Journal, 14, 24–37.
Kazdin, A.E. (2008). Evidence-based treatment and practice. American Psychologist, 63, 146–159.
Larson, E. (2007). Physicians should be

civic professionals, not just knowledge workers, American Journal of Medicine, 120, 1005–1009.
Lauer, M.S. (2002). Cardiologist on trial: Reflections on credible evidence. Journal of the American College of Cardiology, 40, 563–564.
Lilienfeld, O. & O’Donohue, R.T. (2006). The great ideas in clinical science: 17 principles that every mental health professional should understand. Hove: Routledge.
McNeil, D.E., Fordword, D.R., Weaver, C.M. et al. (2008). Effects of training on suicide risk assessment. Psychiatric Services, 59, 1462–1465.
Moran, D.J. & Malott, R.W. (2004). Evidence based educational methods. Elsevier Academic Press.
Reed, D., West C., Mueller, P. et al. (2008). Behaviors of highly professional resident physicians. Journal of the American Medical Association, 300, 1326–1333.
Riggio, R.E. (2008). Leadership development: The current state and future expectations. Consulting Psychology Journal, 60, 383–392.
Rutherford, W.H. (1986). The responsibility of emergency medicine to the prevention of road accidents. Archives of Emergency Medicine, 3, 163–176.
Rynes, S., Gerhart, B. & Parks, L. (2005). Personnel psychology: Performance evaluation and pay for performance. Annual Review of Psychology, 56, 571–600.
Scoville, W.B. & Milner, B. (1957). Loss of recent memory after hippocampal lesions. Journal of Neurology Neurosurgery and Psychiatry, 20, 11–21.
Smith, W.R. (2007). Pseudo-evidence based medicine: What it is, and what to do about it. Clinical Governance, 12, 42–52.
Sutkin, G., Wagner, E., Harris, I. & Schiffer, R. (2008). What makes a good clinical teacher in medicine? A review of the literature. Academic Medicine, 83, 452–466.
van Weert, C. (2004). Visitatie – Study of the new developments in visitatie/peer review programmes in the United Kingdom and The Netherlands.  Retrieved 10 May 2005 from www.caspe.co.uk/expert/nl-uk.htm
Vohs, K., Mead, N. & Goode, M. (2006). The psychological consequences of money. Science, 314, 1154–1156.
Weigelt, J., Brasel, K., Bragg, D. & Simpson D. (2004). The 360-degree evaluation: Increased work with
little return? Current Surgery, 61, 616–628.
Wilson, B.A., Gracey, F., Evans, J.J. & Bateman, A. (2009). Neuropsychological rehabilitation: Theory, therapy and outcomes. Cambridge, Cambridge University Press.
Williams, A. (1990). EuroQol – A new facility for the measurement of health-related quality of life. Health Policy, 16, 199–208.
Winstone, W. & Gervis, M. (2006). Countertransference and the self-aware sport psychologist: Attitudes and patterns of professional practice Sport Psychologist, 20, 495–511.
Wood, L., Hassell. A., Whitehouse. A. et al. (2006). A literature review of multi-source feedback systems within and without health services, leading to 10 tips for their
successful design. Medical Teacher, 28, 185–191.

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