From evidence-based to evidence-reflected professional practice
Christian T. Lystbaek, University of Aarhus, Denmark
Introduction
“Knowledge” is of the utmost significance for professional practice and learning. It is, of course, salutary to remember that professionsare structures of power and privilege, which is why, for some, the rise of professions is a story of knowledge in triumphant practices, whereas for others it is rather a sadder chronicle of monopoly and malfeasance, of unequal justice administered by servants of power(e.g. Abbott, 1988). But, both proponents and its counterpart regard knowledge or expertise as the prime source of professional power.
Today, though, the established knowledge base is changing in all areas of the labour market (Alvesson, 2004). And it is changing in many ways. It is becoming more specific and specialized, while at the same time expanding and broadening its claim to validity and application. For example,today, evidence-based practice has become an expectation and fashion, often used to emphasize the grounding of practice in research based knowledge that provides measurable evidence for best practice. But at the same time, there is a growing distrust of the supremacy of this kind of knowledge, and traditional monopolies of knowledge are challenged (Gabbay & May, 2010). Further, the concerns of both citizens´ rights and the increasing cost of public services have given rise to prominent accountability measures framed by a complex web of state regulation to promote the potentially conflicting aims of efficiency, effectiveness, responsiveness and quality. Thus, cynics might argue that whereas the State previously sought to protect its citizens from the unqualified practitioner, it now seeks to protect them from the qualified.
Thus, the professions and maybe especially the so called “younger professions” (e.g. social work, health care) are facing a turbulent and challenging time. Work and society are dominated by commitment to demands for high levels of demonstrable accountability, cost-efficiency and measurable quality. Not only professionals themselves but also their clients and even more their administrators raise heavy demands on the knowledge and expertise of professionals. As such, the professions have become subject to contested and competing views on what characterizes “good practice”, what we know about it and how to achieve it.
Due to the enormity and diversity of the literature, it is not possible to outline and review the literature in detail in the space of this paper. Thus, I will sketch an overview (painting with a broad brush), rather than presenting a detailed critique of specific theories. This approach may feel unsatisfactory to those who value any particular theory/conception of vocational knowledge. But the paper is concerned here with the bigger picture. It is concerned with the underlying assumptions on fundamental questions, such as: What is knowledge? And how is it relevant to organizational practice? I will call these two fundamental questions the Problem of Rigor and the Problem of Relevance, respectively.
Taking a Wittgensteinian approach, I suggest the need to move beyond current ideas of an evidence-based practice towards an evidence-reflected practice, which involves critical inquiry into the different sources and forms of professional knowledge. Taking this approach, professional knowledge is regarded not as a fixed base, but as a field of ambiguity, contradiction and multiple meanings.
I will proceed as follows: Firstly, I will argue that (1) the concept of knowledge is central to the professions. Secondly, I will argue that (2)theconcept of knowledge involves different styles of reasoning, which is essentially contested.Finally, I will argue that (3) an acknowledgement of the concept of professional knowledge as being an essentially contested concept and, hence,as being sensitive to ambiguity, incoherence, multiple meanings and contradiction within professional practice and learning, represents a move beyond current ideas of an evidence-based practice towards a conception of an evidence-reflected practice in which professional knowledge is regarded not as a fixed base, but as a field of ambiguity and multiple meanings which organization members are trying address both questions of rigor and of relevance of what they are doing.
1.Knowledge as a marker of professional jurisdiction
As stated in the introduction, “knowledge” is emphasized as central and fundamental characteristic, a key constituent of professional practice and learning. Often, professionalism connotes the possession of an exclusive body of knowledge and a highly developed level of skill. For example, what distinguishes professions from vocations, according to a common understanding, is exactly the character of the knowledge base. This common understanding is articulated amongst others by Wilbert Moore, who states that a professions is based upon ”the application of general principles to specific problems” whereas a vocation is based upon ”customary activities and modified by the trial and error of individual practice.” (Moore, 1970:56)
Accordingly, conceptually or (ideo)logically, the concept of “profession” identifies an occupational group as being different from “vocations”. Often, this difference is described as the difference between
- vocations in which what matters is what works as this is informed by tradition and personal experienceand
- professions in which what matters is not only what works but also why and how as this is informed by general knowledge and technology.
Further, the concept of “profession” is different from other scientific occupational groups, namely purely academic disciplines. Often, this difference is described as the difference between
- academic disciplines in which what matters is what is true (or false)as this is informed by scientific research and
- professions in which what matters is not only what is true but also how this can inform and be put into practice, i.e. how this can be made to work.
Hence, it is the possession of specialized practical skills premised on a specialized knowledge base, which provide professions with the jurisdiction to address certain tasks as “professional problems” (Abbott, 1988:59). This is what differentiates a profession as a distinct group from other occupational groups. In other words, it is the possession of specialized practical skills premised on a specialized knowledge base that differentiates a profession from on the one hand vocations and academic disciplines and on the other hand from other professions.
The jurisdiction of rigor
According to the Stephen Toulmin, this conception of professionalism and professional knowledge is developed through the professionalization processes of the scientific and industrial revolutions from 17th-18th centuries and onwards, in which certain methods of inquiries came to be seen as serious or “rational” in a way others were not.
Traditionally, vocational knowledge was acquired on the job, closely guarded within the vocations and handed on from one generation to the next in individual or small group tuition. Expertise arose as a product of the quality of the master’s competence, tuition and feedback and the work-based experience of the learner. But in the process of professionalization, both the character and conception of professional knowledge and learning changed fundamentally. From 17th-18th centuries and onwards, scientific methods of inquiries came to be seen as serious or “rational” in a way others were not. The new scientific form of knowledge became the norm of knowledge. Consequently, scientific views on method and rationality got a naturalised character. Whereas it seemed to describe knowledge, it rather served to prescribe what was to count as knowledge. Subsequently, professional expertise became synonymous with scientific rigour and evidence-based practice. As Donald Schön has pointed out, “according to [this] epistemology of practice, craft and artistry had no lasting place in rigorous practical knowledge” (Schön 1983:34). The practical art of previous times were sought to be replaced by applied science. Thus, beside the rationality of the sciences, the reasonableness of experience came to seem a soft-centred notion (Toulmin, 2001:15). Toulmin sums up this history by stressing that ”intellectually, Descartes´s use of geometry as a model for knowledge provided its slogans; institutionally, the division of labour into professions and disciplines gave it wings. But the change did not happen quickly, and it has reached its peak only in the 20th century.” (Toulmin, 2001:29)
Donald Schön, Stephen Toulmin, and many others has pinpointed that today, thispositivist og scientistic conception of professional knowledge has had tremendous effect on dominant ideas and institutions of professional knowledge and learning. It is built into the very foundations of the institutions and normative curricula of professional education. For example in the influential work of Edgar Schein, one finds thisconception of professional knowledge as “applied science” in his suggestions to a normative curriculum of professional education.
According to Schein, “[p]rofessional knowledge can be thought of as consisting of three elements:
1.An underlying discipline or basic science component upon which the practice rests or from which it is developed.
2.An applied science or “engineering” component from which many of the day-today diagnostic procedures and problem solutions are derived.
3.A skill and attitudinal component that concerns the actual performance of services to the client, using the underlying basic and applied knowledge.”
(Schein, 1973:43)
This hierarchical separation of knowledge, application and skill supposes that, fundamentally, there is only one type of knowledge on which professional practice is to be based, and that is knowledge derived from research or other scholarly activity. Following Schein, professional education should be ordered according to the order of the components of professional knowledge.
This idea has become widespread and is often found in the order of the curriculum in professional education (e.g. Eraut, 1994). Usually, the professional curriculum starts with a systematic knowledge base, largely, though not exclusively, based on contributing academic disciplines, such as the natural and social sciences. This is followed by the applied science elements, which involves the interpretation and application of the knowledge base to practice. This is usually called “practicum” or “clinical work” and is gained through supervised or guided practice in selected placements. Thus, the workplace is presented as a practical field of application for the basic theoretical knowledge acquired in school. Beyond this, workplace learning is dismissed as being ad hoc, incidental and peripheral.
Even continued learning and professional development later in professional life is usually organised in the form of formal courses and educational events. Continued professional learning is usually structured in formally organized courses or educational events off-the-job, rather than work-based learning helping people to investigate their semi-digested case experiences under the stimulus of collegial sharing and challenging (Eraut, 1994:10). Hence, the focus in continued learning and professional development is typically on further specialisation in the form of yet another strand of specialised knowledge – in the form of procedures and artefacts of research, transferred from researchers and textbooks to the professional practitioners in order for it to be applied later, in the varying contexts in professional practice.
Further,this scholastic conception of professional knowledge is also to be found in current discussions around evidence-based practice. The concept of evidence-based practice is often used to emphasize the grounding of practice in research knowledge, which provides measurable evidence for best practice. According to the most common definition, taken from David Sackett, “evidence-based practice is the conscientious, explicit and judicious use of current best evidence in making decisions about the care of the individual patient. It means integrating individual clinical expertise with the best available external clinical evidence from systematic research." (Sackett, 1996) Thus, according to Sackett, the best evidence is found in clinically relevant research that has been conducted using sound methodology, and thus "proved valid through rigorous testing”. (Sackett, 1996)
As such, this conception of professional knowledge addresses the epistemological problem of Rigor, i.e. the problem of how to distinguish knowledge from what is not (but is just an idea, a thought, a belief). Thus, it focuses on the control of the codified knowledge and the monitoring of its flow in professional learning. But it seems to marginalize the epistemological problem of Relevance in the sense that it does not give much notice to the ways in which this codified knowledge base relates to what people in the organization are actually doing.
The jurisdiction of relevance
Increasingly, especially within the last decades, the positivistic conception of professional knowledge described above has been disputed and the perceived hegemony of scientific knowledge challenged. Thus, today, the literature on professional knowledge and expertise is rich on characterizations of the nature and role of various forms of non-propositional or pre-propositional knowledge in professional settings. In this critique of the hegemony of scientific knowledge and theory, the general ethos is that “practice fights back” (Eraut, 2001:vii). Against the common understanding of evidence-based practice it is argued that we rather need practice-based evidence. It is argued that professional knowledge is often tacit and unarticulated and sometimes intuitive. It allows expert professionals to make highly skilled, client-centered judgement through the filtering of what is considered “relevant” often without being conscious of a deliberate way of acting. Professional knowledge is used as an umbrella notion that covers a broad range of features: not only cognitions but also skillful behavior, social norms, routines, values, emotions, etc. As such, it is supposed to cover more or less everything that enables and enhance effective action. Further, there are many attempts to move towards more client-centred forms of professional practice.
Due to the enormity and diversity of the literature, it is not possible to outline and review the literature in detail in the space of this paper. Suffice it to state that a number of alternative conceptions of professional knowledge focus on the problem of relevance. But this focus tendsto bind professional knowledge to effective action. In case of failed action there is simply no or not yet tacit knowledge. But this is of course non-sense. Further, this conception of professional knowledge invites the paradoxical idea that the less one is able to say about what she is doing, the better (more knowledgeable) she might be. Thus, we must re-address the question of rigor (that is, address it but in a way that does not reduce it to scientifically prescribed knowledge) in order to be able to differentiate between “valid” and “invalid”, which does not apply to skilled action.
To sketch an overview of the bigger picture of the discussion on conceptions of professional knowledge, the literature provides a range of epistemological concepts, including
- Scientific knowledge
- Technical knowledge
- Experiential knowledge
- Embodied knowledge
- Personal knowledge
- Practical knowledge
- Intuitive knowledge
- Ethical knowledge
- Aesthetic knowledge
While these concepts are helpful in describing, explaining and analysing knowledge and learning in professional practice and educational settings, they are not clearly differentiated. There are many variations in the way epistemological concepts are described and appliedin the literature, and these are not mutually exclusive. For example, personal knowledge can be embodied and intuitive. And definitions of practical knowledge encompass many of the other forms of knowledge. Thus, many of the epistemological terms overlap in complex ways.
According to some scholars, the concept of vocational knowledge has become fuzzy since it has come to “cover both everything and nothing” (e.g. Alvesson, 2004). Others find that the wide range of terminologies and typologies creates “an epistemological mess” that causes confusion and ruins effective communication and understanding among practitioners, educators and researchers (e.g. Titchen & Ersser, 2001:35).
While I recognize the fear of confusion among practitioners, educators and researchers, I will argue that ending the contestation is neither desirably nor necessary. It is not even possible.
Following Wittgenstein (in his late philosophy, in Philosophical Investigations and On Certainty), knowledge is a distinctive category, i.e. it involves a distinction between knowledge and non-knowledge. But the distinction cannot be drawn once and for all. It is open and constable since it involves multiple and open criteria that cannot be defined once and for all. Consequently, knowledge in general and professional knowledge in particular is an essentially open and contested concept. Thus, no conception hereof is final and all encompassing.
In the following, and final, part of the paper, I will argue that a Wittgensteinian approach offers a way to re-address the question of rigor in order to be able to differentiate between “valid” and “invalid”, but in a way that does not reduce it to scientifically prescribed knowledge, neither to effective action.
2. Knowledge as a marker of professional judgement
In his Philosophical Investigations and On Certainty, Wittgenstein shows howknowledge involves judgments, e.g. judgments regarding the characteristics of a thing, a situation, an action, or something else. And judgments involve criteria, either explicit or implicit criteria, according to which we judge in particular settings and situations.
Thus, to make a judgment(e.g. about a professional problem such as to diagnose a patient, identify a clientandwhat should be done about it, e.g. to decide what kind of treatment the patient should be offered) involves criteria according to which we judge the situation, person or situation as something (a particular person or situation) and judge an action as the proper action.
Thus, one must be able to justify one´s claims to knowledge (knowledgeable judgments) by given reasons.
This approach opens up the huge field of theories on inter-subjective communication. The space of this paper does not allow an exploration into this field, but suffice it to say, that an inter-subjective conception of validity amounts to giving and reflecting on reasons and arguments. As pinpointed by the before mentioned Stephen Toulmin, who was a student of Wittgenstein, if someone raises a claim (C) (fx. “I know what is needed here”, or “I know how to do this”), this claim refers to some data (D) which allows putting forward the claim (Toulmin, 1958; Toulmin, 2001:20)
If the claim is simply believed (and, thus, accepted) or simply disbelieved (and, thus, rejected), the reasons for putting forward the claim remain implicit, not only in the sense that they are not explicated but also in the sense that they are not questioned and hence tested by argument. In other words: In case of acceptance, one simply takes the knowledge claim for granted. This implicit way of dealing with knowledge claims builds the communicative practice of everyday life.