Using theories of professional knowledge and reflective practice to influence educational change

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  • Medical Teacher, Vol. 20, No. 1, 1998

    Using theories of professional

    knowledge and re ective practice

    to in uence educational change

    PATRICIA L. WILLIAMS

    Faculty of Health Care and Social Work Studies, University of Salford, UK

    SUMMARY Theories of professional knowledge and re ective

    practice were used in the development of a new postgraduate

    programme. Central to the curriculum design was the acknowl-

    edgement that a wealth of knowledge creation takes place

    outside the academic setting. The existing experience of practi-

    tioners is an important source of knowledge, and the ability to

    re ect on and share experience is a powerful form of learning.

    These concepts were integrated into the curriculum, and the

    paper gives a number of examples to demonstrate how the

    programme works in practice.

    Introduction

    The purpose of this paper is to describe how the expanding

    and changing role of radiographers in uenced the develop-

    ment of a new postgraduate curriculum. In order to under-

    stand the types of knowledge which are necessary to under-

    take new professional roles, the concept of professional

    knowledge is explored. It is argued that professional

    knowledge should be interpreted with the broadest poss-

    ible meaning, and the context in which knowledge is

    acquired should be viewed as a signi cant factor. Because

    of the value which practitioners place upon the importance

    of their practical experience, the advantages of re ecting

    on and learning from existing experience are contrasted

    with the acquisition of knowledge which has no useful

    professional purpose. It will be maintained that the use of

    re ective practice both assists in the integration of theory

    with practice and enables practitioners to improve their

    skills of clinical reasoning.

    There has been a revolution in radiography practice in

    the last ve years. Central to the aspects driving this

    transformation have been technological advances, socio-

    economic factors and the impact of government policy on

    hospital care. First, technological advances have created

    expert practitioners and have resulted in changes in the

    structure of the workforce especially in the breaking of

    traditional boundaries between professions, as in the adop-

    tion by nurse practitioners and radiographers of tasks pre-

    viously performed by doctors (Chapman, 1993; Loughran,

    1994). Second, the in uence of socioeconomic factors has

    placed greater emphasis on the consumer: for example,

    meeting the expectations of patients/clients for better treat-

    ment and for their inclusion in the decision making about

    the treatment they receive. This emphasis has placed

    greater demands on radiographers whose practice places

    them at the critical interface between the consumer and

    their diagnosis and treatment. Third, the impact of govern-

    ment policy on the health service will radically change the

    context for the delivery of health and social care, with a

    shift in the proportion of work currently undertaken in

    hospitals to primary and community settings. Coupled

    with the change in medical practice, which is shifting the

    balance between curative and preventive medicine, this

    policy raises questions as to the appropriateness of hospi-

    tals as the major places in which radiographers will work

    (Department of Health, 1989a, 1989b, 1992; Williams and

    Berry, 1997).

    Central to all of these changes is the importance of

    effective interpersonal communication. There is an in-

    creasing requirement for radiographers work to involve

    more challenging interactions with patients. Examples of

    these include the discussion of procedures, their risks,

    bene ts and alternatives and the need to assess and cater

    for a wide range of individuals. The result is the develop-

    ment of a climate in which open-ended transactions are

    created of the kind which characterize a professional client

    relationship (Barnett, 1994). This shift in emphasis of the

    role of the radiographer has created the need for a prac-

    titioner who takes a holistic approach to patient care, and

    who balances technological expertise with skill in com-

    munication (Castle, 1988; Caseldine, 1994). But how do

    radiographers acquire this new knowledge? For the ma-

    jority, a large amount of learning will occur in the work-

    place and in general it has been accepted that practical

    experience is at the centre of professional learning (Bines &

    Watson, 1992). Moreover, it is argued that, without this

    focus, it is unlikely that the skills required for competent

    practice will be achieved (Palmer et al., 1994). However,

    the knowledge underpinning practice is elusive, and for

    descriptive purposes is often characterized in several differ-

    ent ways (Oakeshott, 1962; Ryle, 1949; Polanyi, 1967).

    Correspondence: Faculty of Health Care and Social Work Studies, Department

    of Radiography, Allerton Building, University of Salford, Salford, M6 6PU.

    0142-159X/98/010028-07 1998 Carfax Publishing Ltd28

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  • Using theories of professional knowledge and re ective practice

    Therefore, the following part of this paper aims to describe

    professional knowledge, and will argue that such knowl-

    edge is a composite from which it is dif cult to isolate its

    separate parts. This argument will be developed to show

    how learning from experience can be associated with a high

    level of cognitive content so that the knowledge acquired in

    practice can be legitimately incorporated into higher edu-

    cation.

    Professional knowledge

    It has been stated that the nature of professional knowl-

    edge is complex and dif cult to isolate (James, 1993).

    However, for the purpose of description, several authors

    have attempted to tease out its essential meaning into

    several explicit strands. Oakeshott (1962), following Aris-

    totle, makes a clear distinction between `technical knowl-

    edge and `practical knowledge. Technical knowledge is

    understood by reference to the sciences, for example bi-

    ology and physics, and is capable of being assembled into

    a published form. By contrast, practical knowledge is ex-

    pressed only in practice and learned only through experi-

    ence with practice (Eraut, 1985). The tendency to separate

    theoretical from practical knowledge has been followed by

    Ryle (1949) who used the terms `knowing that and `know-

    ing how to describe the distinction. Moreover, Polanyi

    (1967) observed that much of our knowledge is implicit or

    `tacit and cannot always be revealed. However, the separ-

    ation of knowledge into two categories neatly side-steps the

    complexity of its derivation. Eraut (1994), asserts that the

    whole eld of professional knowledge is lacking in trans-

    parency owing to a neglect in conceptualizing the different

    types of knowledge. In an attempt to provide guidance,

    Eraut uses the terms `propositional, personal and process

    to characterize and de ne professional knowledge. Accord-

    ing to Eraut (1994), propositional knowledge comprises

    the disciplined-based theories and concepts which are de-

    rived from bodies of systematic knowledge, and is the

    traditional means by which higher education constructs its

    syllabi. Aligned to these theories are practical principles

    which stem from the applied sphere of professional activity

    with speci c examples of tried and tested cases. The ma-

    jority of this knowledge is in a publicly available, codi ed

    form, although it is argued that personal knowledge is

    in ltrated by propositions, and that publicly available

    knowledge is open to personal interpretation (Grif ths &

    Tann, 1992).

    In contrast with the systematized knowledge which is in

    a published form, personal knowledge is individually ac-

    quired by experience. Eraut (1994) citing Schutz (1967),

    maintains that individuals construct schemes of experience

    which are a composite of our contact with the external

    world and our own personal inner thoughts and feelings.

    Many experiences are simply lived through unless the `act

    of attention halts the process and confers a meaning on

    the experience, the depth of which depends upon the

    purpose of the attention. Much of this knowledge will be

    taken for granted and not subjected to further analysis.

    However, should attention be focused deeply upon experi-

    ence then it can be comprehended in a meaningful way.

    Schutz (1967) argues that:

    the re ective glance will penetrate more or less

    deeply into lived experience depending on its

    point of view. (p. 105)

    For purposes of description, both personal and proposi-

    tional knowledge are easy to separate, but during pro-

    fessional practice, the two strands are inextricably inter-

    twined. Nevertheless, these two forms of knowledge are

    not adequate when explaining the nature of professional

    work: a third dimension is required to complete the pic-

    ture. This is because the majority of professional activity is

    concerned with the performance of techniques and proce-

    dures which Eraut (1994) calls `processes . According to

    Eraut, process knowledge can be de ned as:

    knowing how to conduct the various processes

    that contribute to professional action. This in-

    cludes knowing how to access and make good use

    of propositional knowledge. (p. 107)

    So, embedded in process knowledge is both personal and

    propositional knowledge. In order to illustrate the features

    of process knowledge, Eraut (1994) names ve types of

    process which are typical of professional action. These are,

    acquiring and giving information, skilled behaviour, plan-

    ning and decision making, and the metaprocesses which

    are used to direct and control one s own activities. Each of

    these aspects of process knowledge is dependent to some

    extent upon the personal and propositional knowledge of

    the individual. For example, giving information is a major

    part of the role of many professionals. In oral communi-

    cation, the key to a successful encounter is to listen care-

    fully and to interpret information into a form which a

    client can easily understand. However, this interpersonal

    process draws on the propositional knowledge of the indi-

    vidual as well as his/her personal experience of previous

    situations. Should a similar kind of analysis be applied to

    any of the other types of process knowledge, it would be

    revealed that it is impossible to describe professional ac-

    tivity in the discrete forms which are so useful for the

    purpose of conceptualization. The reason for this mis-

    match between the concept and the reality lies in the true

    nature of practice. During professional action, knowledge

    becomes a dynamic integrated `whole which is shaped and

    adapted to t each situation which is encountered. There-

    fore, the context in which knowledge is acquired and used

    is an important factor.

    According to Eraut (1985), there are three main types

    of context. First, the academic context which is character-

    ized by written communication in traditional formats, for

    example research papers, essays or dissertations. Second,

    the organizational context of policy discussion where a

    group of people exchange views and opinions about certain

    policies and practices. Finally, there are a range of action

    contexts, in which the professional practitioner is in a

    `doing situation. In contrast with the previously men-

    tioned contexts, here the emphasis is on action rather than

    theory. Moreover, because they take responsibility for their

    actions, practitioners require both self-conviction and in-

    tuition; as guiding principles they rely on rst-hand experi-

    ence rather than abstract concepts.

    Therefore, in the action context, practitioners draw on

    their personal experience rather than theoretical knowl-

    edge. Eraut (1994) maintains that:

    29

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  • P. I. Williams

    The result is an essentially pragmatic orientation

    there is a certain subjectivism in the approach,

    a scepticism about `book-learning and a belief in

    the individuality of each distinct case. (p. 52)

    The primacy which practitioners place upon the import-

    ance of their practical experience is in marked contrast

    with the views of those involved in higher education. For

    example, Barnett (1994) maintains that the incorporation

    of nurse education and other professions into the universi-

    ties has resulted in a downgrading of their distinctive forms

    of knowledge because of the `high marks that higher

    education accords to science and the theory-based tradi-

    tions of learning. However, the value of knowledge which

    is of central importance to providing a service to patients

    and clients is becoming increasingly recognized as valid

    (Schon, 1987; Hewson, 1991; Cross, 1993). This view is

    supported by empirical evidence from a range of profes-

    sions which has found that knowledge that is not perceived

    as professionally relevant is given a low priority by stu-

    dents. It does not matter to students that it is included in

    their curriculum. They will learn such knowledge in order

    to pass examinations, but it will soon be forgotten. Subse-

    quently, unless it is used for a professional purpose, then it

    does not become part of professional knowledge (Eraut,

    1994). From this perspective, knowledge should be inter-

    preted with the broadest possible meaning, and once it is

    accepted that all kinds of knowledge are necessary to

    effective professional performance, each should be given

    equal value by higher education.

    The foregoing argument has many implications for

    professional education because its conclusions are in direct

    opposition to the existing system. Currently, there is a

    tendency by educators to `frontload curricula with theory

    (propositional knowledge) at the expense of knowledge

    which is useful and pertinent to practice. Evidence from

    many studies con rm this view. For example, Gott (1984),

    Melia (1987), Baylis (1987) and Grahn (1989) all con-

    cluded that education programmes for health care practi-

    tioners provided students with an idealized theoretical view

    which failed to prepare them for the real world of practice.

    Therefore, questions must be raised as to whether a two-

    step approach of developing knowledge/theory within a

    classroom, and then applying it to practice, can really

    develop the skills required to respond to the unique situa-

    tions encountered during clinical experience. According to

    Eraut (1985), this `applicative approach to the theory

    practice relationship limits both the potential use of theory,

    and the capacity to interpret, re ne and improve practice.

    By its nature, it almost bypasses the process of clinical

    reasoning.

    Although much of the foregoing evidence stemmed

    from research into initial professional education (IPE), the

    argument can also be applied to curricula which are de-

    signed for continuing professional education (CPE). Gen-

    erally, when CPE is supported by employers, the emphasis

    is likely to be on the acquisition of new knowledge rather

    than improving the quality of current practice. This leads

    to a situation where there...

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