Pillars or Knot?

The idea of pillars of practice will be familiar to many who dip into this blog. It’s an idea which has gained prominence through work to develop advanced practice during the last few years. In the Health Education England Multiprofessional Framework for Advanced Clinical Practice, advanced level capabilities are set out in relation to each pillar: Clinical, Leadership, Education and Research. At the recent Health Education England Conference for Advancing Practice: Empowering People, Transforming Care, I sensed advanced practice colleagues are really beginning to embed these four pillars in practice and to embrace professional development beyond the clinical pillar. Indeed, the pillars are a useful reminder that there is more to safe and effective healthcare practice than a well-developed and evidenced portfolio of clinical practice knowledge and know-how and that it is when the clinical pillar is combined with research, leadership and education that we can create solid foundations for each practitioner’s platform for practice.
While advanced practice has drawn attention to these pillars, they should not be regarded as the preserve of those working at an advanced level. From healthcare assistants to those in pre-registration training and onward post-registration career path, practitioners and the public are better served when there is a range of professional development across the pillars of practice. Newly registered health professionals have a tendency to focus on ‘ticking off’ clinical competences, often in quite an isolated way and without recognising the value of the other pillars. Practice is strengthened when combined with critical consideration of the research evidence underpinning clinical knowledge and skills, (an important first step in landing the research pillar in practice), applying education pillar knowledge to facilitating patient health literacy or learning a new technique to support the management of a health condition and drawing on the leadership pillar, in small but important ways, like contributing to decisions about patient care in a multi-professional handover meeting. Furthermore, as a clinician progresses beyond an early career post there is generally an expectation that the practitioner can now supervise others. All too often, these early career practitioners become ‘supervisors’ with little or no structured education and/or leadership pillar investment or development. It would be unthinkable to take on a new clinical responsiblity in the absence of relevant knowledge and skills development. For many, this early focus on the clinical pillar becomes an established pattern, persisting long into the practitioner’s career. I concede that I too was slow to recognise the value of investing in my own professional development across the pillars of practice. The pillar metaphor is helpful in prompting us to think about the need for development beyond the clinical pillar and perhaps helping to evaluate where our developmental preferences and gaps are. However, visualising these dimensions of practice as individual pillars misses how these different strands of practice are, in reality, more intertwined and importantly that our practice is strengthen when these strands are woven together. So, I share here an alternative metaphor where the threads of practice are stronger when knotted together: