the relevant trials on a given question. Systematic reviews represent the best evidence on the effects of interventions. Meta-analysis is the statistical technique for assembling the data from several studies in a review into a single numerical estimate. There is also a move to valuing systematic reviews of qualitative research as well as mixed-methods research.
Questions that need to be asked of evidence are:
Validity – can you trust it? Impact – are the results clinically important? Applicability – can you apply it to your service users?
Clinical Reasoning
Clinical reasoning shares many of the same ambitions as EBP. Higgs et al. (2004, p. 191) suggest it ‘provides the means of examining the relevance of knowledge to specific practice situations’. Traditionally it can be described as a process that combines a specific body of specialised knowledge with cognition, metacognition (thinking about thinking), and contextual considerations. There are a number of theories about how that cognition is defined using terms such as hypothetic deductive reasoning and pattern recognition. These are theories are about how clinical reasoning is determined not about what it actually is.
There is a similarity here with the basic definitions of EBP. Both health paradigms, that is clinical reasoning and EBP, look at the relevance of knowledge when applying it to the individual patient. Both have separate development traditions and literature but there is an overlap. EBP and clinical reasoning ask that knowledge is assessed so that as health practitioners it can be applied effectively. In order to assess propositional knowledge, we have to be able to use critical faculties to appraise it. Critical appraisal of propositional knowledge requires some understanding of research method, because this is how a great deal of health literature is generated. Beyond that, ensuring that the assumptions embedded in scholarship are made obvious is an important skill, and one that comes with practice and reflection.
To assess professional or craft knowledge, the heuristics (mental shortcuts) and biases to which all humans are vulnerable need to be uncovered to assess their appropriateness. This requires reflection on practice, more usefully employed using one of the many established models of reflection.
Personal knowledge occurs when other types of knowledge are employed and absorbed and experienced in practice (Fish and Coles 1998, p. 44). The healthcare worker views this acquired knowledge as his or her own. It is based in the values and ethics of the individual and is often difficult to articulate. When comparing this personal knowledge to an espoused knowledge of practice, using a reflexive debate, learning can take place.
These three types of knowledge are all distinct and require skill and thought in order to embed within practitioners or students. Reflection and reflexivity are important ways to not only understand and ‘own’ knowledge for practice but also to improve and, even more crucially identify, ineffective practice.
We have defined professionalism and discussed a wider definition of knowledge. Common methods of applying that knowledge into professional practice – EBP and clinical reasoning – have been discussed. It has been suggested that reflection and reflexivity are important methods to uncover the complex knowledge used in practice. The following section examines reflection and gives case studies to help the reader deepen their understanding.
Reflection in Practice
Being a reflective Allied Health Practitioner is core to the successful implementation of quality interventions for the individuals and communities with whom we work. As outlined earlier in the chapter, EBP and clinical reasoning are interlinked and a key process for implementing change in practice is reflection. It is crucial that you are reflexive by reflecting on your idea of what you value as knowledge, and therefore becoming more aware of what you would recognise as having value to influence or amend your practice. Throughout this section, examples drawn from a range of health and social care professionals will highlight where EBP has been used to inform practice and move knowledge forward to improve the quality of service provision. Reflection is vital to uphold the standards of professional practice, and in most contexts essential for successful professional registration.
Critical Thinking Is Not Possible without Reflection
To use evidence to enhance your professional practice, you firstly need to see the need to review, change or develop practice, which requires reflection. Thinking critically to amend practice is a reflective process that requires the ability to critique evidence to make a judgement on the quality, and therefore value of, the evidence before considering how to put any changes into practice. Healthcare practitioners often jump straight to an action plan, taking little time to review or reflect again on whether the implementation of the action plan has enhanced practice through applying the knowledge gained. Core to this reflection are the views of key stakeholders whether that is patients, service users, colleagues, or managers. The reflexive element when engaging in reflection as part of EBP is often overlooked. Being a reflexive practitioner involves an individual considering whether their underlying beliefs and assumptions have been challenged or altered due to the critical engagement with evidence and observations of any change on practice.
Reflection and Reflexivity
Reflection and reflexivity are terms that are frequently used interchangeably although there are distinct differences. Reflection has been encouraged for several decades for practitioners within health and social care and is often defined as a process. It is viewed as fundamental to the professional development of health and social care practitioners and a core competency which has been essential during the COVID-19 pandemic (Walpola and Lucas 2021). Promoting and undertaking reflection ultimately seeks to ensure the quality of care provided for service users and should be undertaken by practitioners and managers (Stonehouse 2015). Reflexivity is a lesser understood term with roots in the philosophical underpinning of research. Self-reflexivity relates to exploring and highlighting your own values, particular biases, and preferences related to the research or topic area (Tracy 2010). As with researcher roles, health and social care practitioners can benefit from considering the influence of their own background and assumptions.
Often referred to as deep reflection, reflexivity has a stronger focus on exploration of values, assumptions, and beliefs that inform the professional practice provided. Being reflexive is essential in order to become more self-aware and to question further our actions, and the evidence we use, to inform clinical decision-making. A reflexive process involves an individual looking back and reflecting on themselves in order to emerge or move towards desirable professional practice (Johns 2017). Also, as a reflexive practitioner, it will not only increase self-awareness but also assist in identifying where there may be differing values underpinning other professionals’ actions. Increasing awareness of this can assist with group reflection and explain where differing assumptions may inform clinical reasoning and different approaches to practice.
Case Study 1 – Interprofessional Collaboration: Differing Assumptions Informing Ideas
When working with younger people with dementia, and their caregivers, an occupational therapist and a mental-health nurse reflected on how any service development should evolve. Both healthcare practitioners were passionate about providing a quality service and shared core values of respect, dignity, and compassion. Through reviewing the evidence base, of which there was little at this time, and speaking with the service users regarding their preferences, it became apparent that their own assumptions and clinical reasoning differed regarding the relevant type of setting for the service. Although both professionals were motivated to create a quality service, without taking time to engage with stakeholders and reflect on their own values and assumptions, the service developments could have gone in the wrong direction. An initial
