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 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