Chapter 1
Reflection
The Link between Professionalism, Evidence-Based Practice, and Clinical Reasoning
Keith Walker & Alison Warren
Chapter Overview
This chapter discusses the mechanisms Allied Health Professionals (AHPs) use to assess the relevance of knowledge to their practice. The Health and Care Professions Council (HCPC), in their standards of proficiency for regulated AHPs (HCPC 2013a, 2013b, 2014, 2018), demand that they are able to demonstrate that they can critically reflect on practice, as well as being able to draw on relevant information to guide practice.
What is professionalism? How does professionalism relate to the practice knowledge healthcare workers need? What are the ways in which these workers use their professional knowledge to come to decisions about what they do? These are complex but important questions. It will be helpful to locate them within commonly used terms about knowledge and healthcare. Firstly, professionalism will be defined and its relationship to the knowledge a healthcare worker needs and uses. Common terms used to reflect how AHPs deal with this knowledge are ‘evidence-based practice (EBP)’ or ‘clinical reasoning’, so both of these terms will need some explanation. Finally, this chapter will make the case for reflective practice as a cornerstone of professionalism, EBP, and clinical reasoning.
Professionalism
Professionalism has been difficult to define. It has many attributes claimed, and these attributes often change given the author and the times. There are however common themes; professionals are expected to demonstrate a key set of behaviours that reflect the values, knowledge base, and attributes of the profession in which they work. These standards are usually explicit within in each profession and appear as a code of standards, proficiency, or conduct. They are informed by more than the law of the land but also by ethical considerations. Integrity and altruism are expected and this is particularly important in healthcare.
Clinical reasoning and decision-making feature consistently. AHPs are expected to have a specialised, bounded, and privileged bank of knowledge. It is, by its very nature, not easily understood by others and thus professionals are expected to interpret that knowledge base for the betterment of others. To summarise, a professional is asked to behave to a set of standards and interpret a specific bank of knowledge, delivering that interpretation in the best interests of their clients or patients.
We are concerned here with the knowledge base as an expression of professionalism. Simply obtaining that knowledge base is a key barrier to entry for the professions. This is reflected in the high tariffs required by higher-education institutes and regulators for admission into healthcare courses and the accreditation of healthcare courses themselves. There is also the task of maintaining and improving the working knowledge that each professional carries. When regulators demand that registrants behave professionally, part of that demand is that they keep their knowledge up to date. This is demonstrated by the regulatory oversight of a continual professional development system without which AHPs are not able to successfully apply for re-registration.
The acquisition and maintenance of a knowledge base therefore is a key characteristic of a professional. Moreover, society places a trust in professionals to interpret this knowledge for them (van Mook et al. 2009). It is this interpretation that is the subject of this chapter.
Knowledge
In the last section, the relationship between professionalism and knowledge was outlined. In this section, knowledge and its definitions and characterisation will be explored. There are several critical theories of knowledge, but knowledge should not be taken simply as a series of facts strung together like beads. There is an element of interpretation involved whenever and whatever professional knowledge is used. Once we have determined what sort of knowledge is being used, we have to decide how we judge its authenticity.
Higgs and Titchen (1995) refer to three important types of knowledge – propositional, professional, and personal knowledge. Propositional knowledge is acquired through the study of books, articles, teaching, etc. Professional knowledge is that which practitioners develop in respect of their craft. It is generally difficult to source or describe to others. Personal knowledge comes from theoretical insight and an examination of values and ethics.
With this sort of delineation of the types of knowledge, there comes an appreciation of the complexity of understanding that a professional has to juggle to come to accurate and appropriate decisions about the healthcare they provide. It highlights the inadequacy of a position that states that propositional learning alone can account for expert professional practice. Professionals need to understand the various ways that they might learn. It is by understanding this complexity that they can adjust their learning and the examination of their knowledge base to develop as professional healthcare providers throughout their career. Although these types of knowledge might be distinct, they inform each other and are intimately connected. They are mutually transformative; hence the advance or change in one informs the other (Higgs et al. 2004).
Conceptions of Practice
The connection between how healthcare practitioners deal with knowledge in their practice lives has been characterised in the past as a continuum between technical rationality and professional artistry. Technical rationality is instrumental problem solving made rigorous by the application of scientific theory and technique (Schön 1983, p. 21). It is placing theory and the learning that is needed as a necessary step before practice can be mastered. Technical rationality assumes that theory is an essential precursor to practice; without it practice is impossible. It relies on the practitioner ‘receiving knowledge from others to enable them to practice’ (Rolfe et al. 2001, p. 11).
On the other hand, professional artistry are clinicians that are challenging knowledge and its currency. They are creative and are happy to embrace uncertainty. Theory emerges from practice. Post graduate study is one means to promote critical thinking (Thomson et al. 2014).
If we understand that theory is not simply the precursor to knowledge and therefore practice but an important ingredient in how care is delivered, then we have to begin to engage with it as something that is alive and adaptable whilst we practice. Learning the skills of reflection and becoming a reflective practitioner are important steps to achieving this.
The ways that healthcare practitioners are expected to come to decisions about the care they deliver are often described as EBP or clinical reasoning. Do these two concepts offer any help when it comes to relating knowledge to practice?
Evidence-Based Practice
Acquiring knowledge and keeping it up to date requires an understanding about how practitioners gather and evaluate knowledge that apply to their area of practice. The most pervasive method of judging the relevance of information in today’s healthcare decision making is referred to as EBP (Sackett et al. 1996). This is commonly defined by linking the realms of best evidence, clinical expertise, and patient interest.
As an Allied Healthcare Professional it is essential that everything you do is based on best evidence. The aim of pre-registration graduate training is to start the process of developing evidence-based literate graduates. This is a process that will never end, since we are constantly looking to evidence what we do and to refine the skills we have been taught, and of course to build capacity within the professions to improve quality and effectiveness of practice. Simply using whatever research evidence you happen to obtain from reading the few journals that you subscribe to is not going to sufficiently meet your information needs or keep you updated (Hoffmann et al. 2013, p. 3).
So why is EBP so important? The easiest way to answer that question is to consider whether you would trust a doctor who prescribed you a drug without knowing whether it was effective or had gone through rigorous testing to ascertain its safety and reliability. For service users, they need to trust that our interventions will not cause harm and that we are using the best guidance and evidence. When the outcome of treatment is harmful in some way, the non-evidence-based approach strays into the realms of professional negligence if a treatment regimen was pursued contrary to the evidence. In a world where patients are better informed about standards of care, litigation in healthcare is becoming increasingly common. A second problem is bias. A non-evidence-based approach relies on the knowledge and experience of the individual, which is naturally subject to personal preference and prejudices, some of which will not be evidence-based.
EBP therefore has an issue with knowledge, how it is generated, and what type ‘counts’ (Rycroft-Malone et al. 2004). It discounts or significantly downgrades knowledge that is generated in ways other than those that adhere to a very positivist view of epistemology. In other words, knowledge that is demonstrated by testing established theory. Unfortunately, practice does not always fit into neat puzzle packages to which there are simple solutions. Knowledge that is propositional and derived solely from isolating causes and measuring their effect might not be sufficient to produce effective care. Professionals therefore have to have a way to judge and develop all types of knowledge used in care, to be effective. This gap in the process of decision-making requires an understanding of how knowledge is generated and how we are able to judge the relevance of information to a healthcare question. Reflection is key to interpreting the different types of knowledge applicable to each of the major domains of EBP. Change in one type of knowledge impacts the other.
It is essential that AHPs utilise critical appraisal skills to determine the quality of the research since often evidence is of a poor quality. The aim of a systematic review of the effectiveness of an intervention is to collate all the relevant trials on a given question. Systematic reviews represent the best evidence on the eff...
