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 professions are 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) the concept of knowledge involves different styles of
reasoning, which is essentially contested. Finally, I will argue that (3) an acknowledgement of the
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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
a. vocations in which what matters is what works as this is informed by tradition and personal
experience and
b. 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
a. academic disciplines in which what matters is what is true (or false) as this is informed by
scientific research and
b. 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.
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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, this positivist 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 this conception 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.
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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, “evidencebased 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 tends to
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
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




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 applied in 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 nonknowledge. 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 how knowledge 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 client and what 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
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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.
But, if knowledge/validity claims are questioned, this calls for arguments in terms of reasons to
believe the knowledge claim. In other words, if the move from D to C is called into question, this
implies that the validity of the claim is questioned and the proponent has to give further reasons to
support the claim. In other words, the conclusion has to be supported by warrants (W). These must
be of a different type than D, otherwise the warrant would just be a repetition of what has already
been said. As such, warrants are logical deductions which allow concluding C from D enforced by
further backing (B).
According to this Wittgensteinian approach, the differentiating feature of knowledge is whether
validity claims are reflected or not. Knowledge can only be attributed if a knowledge claim has
been questioned and turned out as (convincingly) valid in an argumentative process. If a claim to
knowledge has not passed this discursive “validity test”, it is not to be regarded as knowledge.
Thus, this Wittgensteinian approach restricts the notion of knowledge to those knowledge claims
that have been made subject to questioning and considering of reasons. Thus, this approach
advances a clear distinction between the everyday skill, opinion and habit on the one hand and
knowledge (conceived as the outcome of an inter-subjective reasoning process) on the other. This
implies that knowledge is a communicative phenomenon which is guided by reasons. This does not
rely on objectivity in terms of correspondence with a reality “out there”. Neither does it rely on
ideas of final truth or irreversible proof. As validity is conceived in terms of a discursive reasoning
process, by implication the reasoning is always fragile. One can never claim for final validity, as the
outcome of a reasoning process is in principle prone to fail. It is always possible (and a well-known
fact) that accepted knowledge can prove false if convincing reasons are brought to light.
Contested criteria
It is important to note that the criteria used to evaluate reasons are themselves dependent upon
discursive reasoning. They are, as Toulmin put it (1958): “Field-dependent”. This means that there
is no universal standard for evaluating knowledge claims. Rather, each field of knowledge develops
its own standards. Often (fx. in complex organizations like health care organizations) there are
competing standards and styles of building reasons, fx. through theoretical deduction, practical
exploration, experimentation, etc..
This means that knowledge cannot be considered an exclusive product of one particular criteria of
judgment or style of reasoning, namely science. Rather, scientific knowledge represents just one
type of knowledge that fulfills the criteria of knowledge. Other criteria are likely to generate other
styles of reasoning and therefore other types of knowledge.
In a sense, any particular use of any judgement is liable to be contested for reasons better or worse.
For example, the judgement “this picture is painted in oils” may be contested on the ground that it
is, rather, painted in tempera. Despite their contestation, though, concepts usually carry with them
an assumption of agreement, as to the kind of use that is appropriate to the concept in question,
between its user and anyone who contests his particular use of it. Thus, the statement “this picture is
painted in oils” may be contested, but with the natural assumption that everybody will agree as to
the proper use of the term involved.
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But, according to Wittgenstein, some concepts are liable to be contested because of an evident
disagreement as to the proper use of the concept. Such concepts will never meet the assumption that
everybody will agree to its proper use. Examples of such concepts are, amongst others, the concepts
of “work of art”, “social justice” and “democracy”. Such essentially contested concepts are
characterized by
(i)
being appraisive in the sense that they signify or accredit some kind of valued
achievement,
(ii)
the accredited achievement is attributed to the achievement as a whole, while this is of
an internally complex character, and, hence, variously describable,
(iii) the accredited achievement is open in the sense that it admits considerable modification
in the light of changing circumstances, but such modification cannot be prescribed or
predicted in advance.
These characteristics imply that there is no clearly definable general use which can be set up as the
correct or standard use of concepts with these characteristics. On the contrary, concepts with these
characteristics are essentially contested concepts.
I will argue that the concept of “professional knowledge” is an essentially contested concept in this
sense. Both today and throughout the history of professionalization, the concept of “professional
knowledge” has been continuously contested, and for reasons that are not hard to find. The concept
is mainly (at least among professionals) an appraisive term, but the achievement it accredits is
variously describable because in different times and in different circles it has seemed both natural
and justifiable to describe it with a dominant emphasis on different aspects of it.
Against this line of argumentation, it might be argued that the concept of “professional knowledge”
is not really essentially contested, but just accidentally contested, as a result of persistent confusion.
That is, the use of the concept might be thoroughly confused in the sense that it covers the possibly
perfectly consistent use of two or more concepts which only need to be discriminated. Thus, the
contestants are not playing the same game, but different games and therefore not essentially, but
only accidentally, contesting the use of the concept. Hence, it might be argued, the concept of
“professional knowledge” is only accidentally and not essentially contested.
But, if this was the case, it might well be expected that once the variety of uses and functions of the
concept of “professional knowledge” is disclosed the dispute will come to an end. But in fact, this
does not happen. Because of the internally complex and variously describable character of the
concepts of “professional knowledge”, different features in it are differently weighted by different
appraisers. Different uses of these concepts sub serve different, though of course not altogether
unrelated, functions for different contestants. Each contestant continues to maintain that the special
use and function which the concept fulfils on its behalf and on its interpretation, is the correct or
proper or primary use. Moreover, each contestant continues to defend its case with what it claims to
be convincing arguments and other forms of justification.
The essentially contested character of the concept of “professional knowledge” goes a very long
way towards explaining the way it functions in epistemological arguments and debates.
Epistemology is not a neutral medium that conveys ideas independently formed; rather it involves
(in the words of Charles Taylor) inescapable but fractured frameworks or horizons for our thoughts
and thinking (Taylor 1989). Epistemology emerged in ancient Greek. Since then, epistemology has
become a set of institutionalized structures of meaning (that is, sets of thoughts and thinking which
have had a “Wirkungsgeschichte” in the traditions and schools of philosophy) that channels our
thinking and action in certain directions (both historically and systematically).
When acknowledging and appraising the power and enjoyment of knowledge, we tend to
concentrate our attention, primarily and predominantly, on only one or few aspects of it. In this
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way, we can conscientiously sustain and perhaps even advance our way of knowing as
circumstances permit. Hence, we can be assured that we “play the game” (that is, know). But just
the same holds true of the other contestants. Hence, to use an essentially contested concept is to use
it against other uses and, thereby, recognize that one´s own use of it has to be maintained against
these other uses. Hence, to use an essentially contested concept means to use it both aggressively
and defensively.
In the final part of the paper I will argue, that an acknowledgement of the contested character of the
concept of “professional knowledge” might change or alter established terms of debate.
3. Conclusion
Today, “knowledge” has more than enough air time. Everybody is talking about knowledge and the
importance of knowledge. The attention to, even obsession with knowledge is one of the defining
features of our present. For quite some time, we have been talking about today´s society as a
knowledge society, the economy as a knowledge economy, and so on and so forth (e.g. Bell, 1973).
Regarding the concept of “professional knowledge” and the descriptions and arguments in which it
figures, there is no clearly definable general use, which can be set up as the correct or standard use.
Different uses of the concept subserve different though of course not altogether unrelated functions
for different schools or traditions in epistemology. The concept of “professional knowledge” an
internally complex concept with a broad and variable set of criteria, and each criterion itself is
relatively complex and open, that is, has complex connections with a host of other concepts to
which it is related (such as truth, meaning, intelligibility, rationality, reasonableness, and so on and
so forth).
While some argue that we need to evidence-base professional health care (and gives this statement a
scholastic interpretation), others argue that we rather need to practice-base evidence in professional
health care.
The view I am reaching for challenges both conceptions of “professional knowledge” and practice.
In the light of the essentially contested character of “professional knowledge”, a purely
interpretative or descriptive approach is neither desirably nor necessary. It is not even possible.
Professional knowledge is not simply an empirical matter, but is, rather, itself an epistemological
accomplishment. The kind of achievement it accredits is internally complex and, further, always
open in character in the sense that no one can prescribe or predict what new development of current
forms may come to be regarded as proper knowledge. There can be no question of any purely
mechanical repetition or reproduction of it. Thus, professional knowledge is not only an empirical
matter of cultivating ideas and practices, but extends to asking “difficult questions” that are neither
a mere prelude to knowledge nor peripheral to it, but central to it – even constitutive of it.
Therefore, I will argue, we must treat the concept of “professional knowledge” as a radically open
and contested concept, that is, a concept that needs to be questioned continuously in professional
settings rather than a concept that is defined, or a question that is answered, before one engage in it.
Thus, to inquire is not a prelude to professional knowledge, but a dimension of it. “Professional
knowledge” is an indispensable, non-fixable marker, challenging every attempt to treat a concept,
settlement, or principle as complete, without excess, remainders, or resistance.
Complex organizations, such as professional health care organizations, may often amount to multicriteria systems, applying different types of criteria at the same time. Such organizations have to
handle different types of knowledge simultaneously. The relationship between these different
discourses might vary from time to time, with one set of criteria momentarily dominating another.
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In such cases, it is part of professional practice to handle the conflicts and complexities arising from
overlapping or conflicting types of knowledge by reflecting upon and evaluating which backing is
the better one.
In relation to professional judgment and decision making, the reasonableness of a judgment or
decision rests not only on the choice of the right means or methods, but also on the ability to weigh
up the different kinds of ends and goals that both professionals and their clients (patients, pupils,
customers, and so on) confront in complex and conflict-filled modern professional practices.
Hence, according to this approach, professional practice involves maintaining discursive procedures
for examining critical and controversial knowledge claims or more precisely its validity claims.
This implies an interpretative, reasoning approach to evidence, i.e. one that is sensitive to
ambiguity, incoherence, multiple meanings and contradiction within professional knowledge. Thus,
this approach moves beyond traditional ideas of a knowledge-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 professionals are trying address both
questions of rigor and of relevance of what they are doing. A closer look at modern health care
organizations will reveal that many professionals already make use of procedures for reflecting on
and evaluating the validity of knowledge claims.
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