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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

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