Reflective practice is a risk to competent clinical practice

Reflective practice is a risk to competent clinical practice

Clare Butler

Reflective practice is key to the development of professional practice in a range of work settings, including the healthcare sector (Schon, 1983). In the context of clinical practice, to work without reflection would be unthinking and un-thinkable.

Yet, research published in the journal Social Science & Medicine highlights the risks that can surround reflective practice in healthcare.

Funded by the Dominic Barker Trust, the project focused on one group of allied-healthcare professionals: speech and language therapists (SLTs). The research sought to better understand ‘the work of SLTs’; as such, in-depth interviews were conducted with thirty-three SLTs working in the UK, across a range of specialities and sectors.

Like many medical professions, competent practice in speech and language therapy is thought to be achieved through reflective practice plus evidence-based practice. Indeed, reflecting on learning and experiences alongside peers is integral to SLTs’ training at university; and this is carried forward into their work as clinical practitioners.

However, based on my research, I argue that it is the combination of reflective practice alongside the drive for evidence-based practice where risks can arise – specifically, the risk of limiting the development and propagation of ‘real’, responsive clinical practice.

Evidence-based practice
Gold-standard clinical practice is often regarded as that governed by a ‘scientific’ evidence-base. Commonly, this is equated to evidence that can be captured, accounted for and evaluated in measurable ways. The most legitimate evidence-base is typically thought to be that which is gathered via randomised control trials (Sibbald and Martin, 1998); drawing on large datasets, quantified and then generalised to the whole population.

In many cases, this fetishisation of ‘hard’ science is set within a neoliberal context. As McGregor (2001:87) argues, neoliberalism in healthcare foregrounds a ‘concern for competition, accountability and consumer demand’ in managing performance. Here, there is a focus on the 3Es and with it the notion that economy, effectiveness and efficiency can be achieved when hard, scientific evidence is lionised and fed through into practices that are streamlined, formalised, documented, taught and then repeated by clinicians.

Undoubtedly, in many clinical contexts evidence-based medicine and practice is infinitely better than the alternatives (Isaacs and Fitzgerald, 1999). However, and importantly, practice that is based on a standardised model does not provide ‘excellence’ in all clinical fields; and not in speech and language therapy, not always.

Speech and language therapy
Speech and language are multifaceted. Communication is relational and situational and infinitely complex; alongside, the manner of its acquisition, development and loss varies in countless ways. Here, patients / clients are individual in their presentation: they (we) are unique, varying case studies. It is for this reason that what’s required in speech and language therapy are interventions that are equally unique and responsive; informed by the particular and not the general.

To be clear, standardised interventions can and do work and there is a robust evidence-base for much speech and language therapy, but neoliberalism and the related call for greater regularisation and more standardisation is restricting relational and responsive practice. In this matter, my study and its participants make it clear that evidence-based practice in speech and language therapy needs to ‘get real’.

Getting ‘real’ means accepting and embracing the reality of people, our uniqueness; and recognising the wide range of practices that can and do offer ‘excellence’ in healthcare. This research therefore adds another voice to the campaign for real evidence-based medicine (Real EBM). A campaign championed by Professor Trisha Greenhalgh in her presentation titled Real vs Rubbish EBM and the Centre for Evidence-based Medicine at Oxford University, UK. In short, the Real EBM campaign argues that the pendulum of generalisation and standardisation in clinical medical practice has swung too far; having a detrimental effect on clients and patients (Greenhalgh et al., 2014).

Reflective practice
Importantly, the research on which this article is based adds another dimension to the ‘real’ evidence-based campaign. Specifically, it underscores that the push for standardisation and privileging of evidence-based practice is also having a detrimental effect on clinicians when together they reflect on their practice.

We know that reflective practice is vital in much professional work (Schon, 1983). In healthcare, reflective practice moves beyond tacit, knowing-in-action; instead, it demands reflexivity, reflection-in-action. Reflection-in-action requires clinicians to be open to being surprised: responsive to the social, the here-and-nowness that surrounds their work practices (Jordan, 2010).

Yet, practices are regulated in a plethora of ways e.g. organisational rules, situational and social norms, and professional ethics. Alongside, sources of regulation can and do compete; often as a result of evidences and/or knowledges having different statuses (Greenhalgh et al., 2015).

As such, my research found that it is when the SLTs reflect on their practice in clinical review meetings – when the demand for evidential evidence-based practice is a performance management issue – that evidence got ‘real’. It raised ‘real’ doubt for the SLTs. Participants spoke of doubting themselves; questioning if their experiential knowing is of value. Against the backdrop of neoliberalism and the fetishisation of evidence-based practice, they questioned if their ‘real’ clinical practice experience should be shared; especially in front of their less-experienced colleagues who are also under significant pressure to learn, develop and use evidence-based practice.

The relegation of ‘real’ clinical practice and ‘real’, competent clinical practitioners?
The implications of my research are clear: ‘real’ clinical practice was not being positively, confidently shared. This raises a significant concern for the speech and language therapy profession, clinicians and clients, but also raises concerns for other healthcare professions where reflective practice is equally promoted. Based on my research, I argue that where evidence-based practice is lauded and, to some extent, demanded by the systems within which clinicians work, rituals of reflective practice risk limiting the sharing of vital, clinical practice experience.

As a result, I call for healthcare policymakers and practitioners to not only consider the drive for evidence-based practice within their clinical field, but also to critically examine how reflective practice regulates / governs the work of clinicians and practitioners. To make progress toward ‘real’, competent clinical practice, it means recognising that 1) clinical practice must be responsive to the individual and 2) the systems within which clinicians’ practice must allow that individual responsiveness.

Greenhalgh, T., Snow, R., Ryan, S., Rees, S., & Salisbury, H. (2015). Six ‘biases’ against patients and carers in evidence-based medicine. BMC Medicine, 13(1):200.
Greenhalgh, T., Howick, J., & Maskrey, N. (2014). Evidence based medicine: a movement in crisis? BMJ, 348.
Isaacs, D., & Fitzgerald, D. (1999). Seven alternatives to evidence based medicine. BMJ, 319, 1618.
Jordan, S. (2010). Learning to be surprised: How to foster reflective practice in a high-reliability context. Management Learning, 41(4):391-413.
McGregor, S. (2001). Neoliberalism and health care. International Journal of Consumer Studies, 25(2):82-89.
Schön, D. A. (1983) The Reflective Practitioner: How Professionals Think in Action. New York: Basic Books
Sibbald, B and Martin, R (1998) Understanding controlled trials: Why are randomised controlled trials important? BMJ, 316 :201

Further Reading:

Butler, C. (2019). Working the ‘wise’ in speech and language therapy: Evidence-based practice, biopolitics and ‘pastoral labour’. Social Science & Medicine, 230, 1-8.


Many thanks to the Dominic Barker Trust for funding the research.  


Clare Butler is Senior Lecturer in Work and Employment at Newcastle University Business School, Newcastle University. Her research explores how regulation is practiced and experienced at work; recent studies have considered professionalism and discrimination. @clarebutler123