The postmodernist war on evidence-based practice

Elucidating the Ruling Relations of Nurses' Work in Labor and Delivery: An Institutional Ethnography

Obstetrics is a well-known area for malpractice and medical-legal claims, specifically as they relate to injuries the baby suffers during the intrapartum period. There is a direct implication for nurses' work in labor and delivery because the law recognizes that monitoring fetal well-being during labor is a nursing responsibility. Using institutional ethnography, we uncovered how two powerful ruling discourses, namely biomedical and medical-legal risk discourses, socially organize nurses' fetal surveillance work in labor and delivery through the use of an intertextual hierarchy and an ideological circle.

Shaping the Qualities, Values and Standards of Science. How Reporting Guidelines Improve the Transparency of Biomedical Research

What is scientific quality and how can it be achieved? Recent developments in clinical biomedicine gave prominence to transparency as a new core value for scientific research. Without transparency, other characteristics and values remain unknown. But how can abstract concepts and values be implemented in day-to-day scientific practices and what gets lost on the way? In order to answer this question, this study investigates the role of the PRISMA reporting guideline for writing systematic reviews and meta-analyses. By combining a document analysis and expert interviews with its developers, it attempts to bridge the gap between research practice and current modes of evaluation. Beside showing how the guideline was designed to be applicable and acceptable as a new standard, the analysis revealed crucial distinctions between transparency as an abstract quality goal and its practical implementation in the form of specifically formulated rules. Although PRISMA relies on transparency in order to be meaningful, it blurs the concept in order to circumvent some of its main disadvantages.

The struggle for safe staffing levels in the USA: a political economy of evidence-based practice

This paper examines the debate over nursing staff to patient ratios through the lens of Marxist political economy, arguing that the owners and controllers of healthcare in the USA have a vested interest in opposing mandated minimum ratios, while those involved in carrying out nursing care have a vested interest in their implementation, which coincides with the interests of patients. We examine how evidence-based practice articulates with social power, and proceed to interrogate the research methods used to generate evidence for practice, noting that randomised controlled trials are not suitable for evaluating nurse/patient ratios, which means that observational studies are the primary source of evidence. Representatives of nursing managers have used the fact that observational studies, while demonstrating an association between high ratios and poor outcomes, have not established a causal relationship, to support their argument that there is not sufficient evidence for the imposition of mandatory ratios. We argue that the precautionary principle provides firm justification for mandatory ratios, unless and until a causal relationship has been disproved. We conclude that those involved in the generation of evidence have to choose between technical arguments about the inferiority of observational studies, or emphasising their sufficiency in triggering the precautionary principle.

Particularizing the general: Sustaining theoretical integrity in the context of an evidence-based practice agenda

Proliferation of demands for accountability and health care quality places nurses under constant pressure to ensure professional practice is evidence-based. The corresponding emphasis on knowledge that pertains to general populations challenges nursing's traditional focus on the uniqueness of each individual patient. Considering how nurses engage with professional systematic thinking processes, we reflect on ways competing agendas in the evidence-based practice environment compromise the professional vision aspired to by an earlier era of nursing model and framework builders. Exploring the scientific thinking underpinning practice evidence, we contemplate implications for applying general knowledge to particular practice, reconsidering options for conceptualizing nursing praxis.

Sources of knowledge used by intensive care nurses in Norway: an exploratory study

This study explored the sources of knowledge that intensive care nurses used in their daily nursing practice. It used a qualitative design based on four focus group interviews with 20 intensive care nurses, from four intensive care units in Norway. Data were analysed using systematic text condensation. The following condensed meaning units were identified: research, theoretical knowledge, experiential knowledge, work place culture, clinical expertise and patient participation. This study illustrates the complexity and variety of the knowledge bases of intensive care nurses. Despite some variation in nurses' familiarity with research literature, nursing interventions found by research to be useful were given priority, and research affected daily practice through changes in guidelines and procedures.

Queer challenges to evidence-based practice

This paper aims to queer evidence-based practice by troubling the concepts of evidence, knowledge and mental illness. The evidence-based narrative that emerged within biomedicine has dominated health care. The biomedical notion of 'evidence' has been critiqued extensively and is seen as exclusive and limiting, and even though the social constructionist paradigm attempts to challenge the authority of biomedicine to legitimate what constitutes acceptable evidence or knowledge for those experiencing mental illness, biomedical notions of evidence appear to remain relatively intact. Queer theory offers theoretical tools to disrupt biomedical norms and challenges biomedical normativity to indicate how marginalisation occurs when normative truths about mental health classify those who differ from the norm as 'ill' or 'disordered'. Queer theory's emphasis on normativity serves the political aim to subvert marginalisation and bring about radical social and material change. Reference will be made to mental health subjects within each discourse by indicating how the body acts as a vehicle for knowing. Deleuzian notions of the rhizome are used as metaphor to suggest a relational approach to knowledge that does away with either/or positions in either biomedical, or queer knowledge to arrive at a both/and position where the biomedical, constructionist and queer are interrelated and entangled in needing the other for their own evolution. However, queer does not ask for assimilation but celebrates difference by remaining outside to disrupt that which is easily overlooked, assumed to be natural or represented as the norm. The task of queer knowledge is to do justice to the lives lived in the name of evidence-based practice and demands that we consider the relations of power where knowledge is produced. This pursuit creates different knowledge spaces where we identify new intersections that allow for socially just understandings of knowing or evidence to emerge.

Bringing values back into evidence-based nursing: the role of patients in resisting empiricism

We examine problems resulting from the narrow empirical focus associated with evidence-based nursing, including the deleterious influence of vested interests, disattention to patients' experiences, underestimation of the importance of social processes, lack of an individualized research perspective, marginalization of other forms of knowledge, and the undermining of patients' autonomy. Addressing each problem in turn, we argue that inclusion of patients at all stages of evidence-based practice can counter or ameliorate these problems. While we concede that patient involvement is not a complete solution to the problem of empiricism, it is the most effective means available to defend nursing values.

Evidence based practice and its critics: what is a nurse manager to do?

AIM(S)

The purpose is to discuss the arguments against the evidence based practice (EBP) movement and suggest how nursing management might respond.

BACKGROUND

EBP is a pervasive approach to directing and regulating nursing care. There are, however, fierce critics who argue that it is fundamentally flawed and detrimental to patient care.

EVALUATION

We consider some of the more radical criticisms of EBP, weighing the arguments and reflecting on the extent to which alleged short-comings are supported in the literature. Postmodernist critics are amongst the most vocal and are therefore our principal focus.

KEY ISSUE(S)

'Best evidence' implies a hierarchical approach to knowledge which excludes other forms of evidence that are needed to understand the complexity of care. Evidence based guidelines tend to stifle critical thinking amongst nurses.

CONCLUSION(S)

While EBP is increasingly open to a range of research methodologies, it still largely subscribes to a hierarchy of evidence, even though this approach to addressing the complexities of healthcare is limiting. Although the EBP approach can be shown to stifle critical thinking, this is not inherent to the approach, which can lend itself to supporting professional nursing practice.

IMPLICATIONS FOR NURSING MANAGEMENT

Nursing managers should neither abandon EBP nor accept it uncritically.

Evidence-based practice: issues, paradigms, and future pathways

Evidence-based practice (EBP) has become a real buzz word, not only in the discipline of nursing, but in all healthcare professions. EBP has been identified as the foundation of accountable, professional nursing practice and it would seem that few could argue with the apparent benefits; however, debate does exist in the literature about whether EBP can realistically be attained. As such, a critical discourse regarding the future of EBP for nursing needs to occur. One of the key questions to be addressed through this discourse is, "what counts as evidence?" A review of the nursing literature on the concept of EBP will be presented in this paper along with a discussion of several of the issues associated with EBP within the discipline of nursing. I will also present some ideas about the implications of the EBP movement in nursing and examine the future pathways for nursing.

Never mind the qualitative feel the depth! The evolving role of qualitative research in Cochrane intervention reviews

Whilst the Cochrane intervention review remains the gold standard, the previous focus on randomised controlled trials and exclusion of other types of evidence limited their utility for some users — especially policy makers and commissioners of services who had to draw on other types of evidence about patient views and context in order to make decisions.

This paper reports a significant development in the evolution of the Cochrane intervention review and outlines an evolving role for qualitative evidence. Policy and methodological developments within the Cochrane Collaboration and beyond will be discussed alongside an ongoing debate about the politics of evidence and perceived power of the quantitative effectiveness review in an evidence-based practice context.

The paper concludes with six key messages, including: (1) the Cochrane Collaboration has consistently acknowledged the potential value of qualitative evidence; (2) Cochrane was an early leader in quantitative evidence synthesis and developed a gold standard approach for effectiveness reviews; (3) early leaders in the field tend to dominate until other approaches are developed, tested and evaluated to challenge early leader dominance; (4) other review organisations and individuals have now developed expertise in qualitative and mixed method synthesis and there is an emerging and developing evidence base with a range of qualitative synthesis approaches for different contexts; (5) there is still a need for further methodological development, testing and evaluation, and (6) finally, more than one hierarchy of evidence is needed to address different types of questions, and the dominance and application of one hierarchy to all contexts is unhelpful and counterintuitive to achieving evidence-based healthcare.

On the problems of mixing RCTs with qualitative research: the case of the MRC framework for the evaluation of complex healthcare interventions

In the perceived hierarchy of research designs, the results from randomised controlled trials are considered to provide the highest level of evidence. Indeed, these trials have been upheld as the gold standard in research. The benefits and limitations of the randomised controlled trial as a method of evaluating the effectiveness of healthcare interventions are presented. The paper then examines the different levels of complexity within healthcare interventions and the problems this poses in determining effectiveness. In an effort to provide a solution to this problem, the Medical Research Council produced a framework to assist investigators to develop and evaluate complex healthcare interventions. The framework is described with reference to an example of implementing and evaluating protocols for weaning patients in the intensive care unit. The framework is critiqued on the basis that it involves an ambiguous or contradictory ontology, which fails to articulate the relationship between the positivism of randomised controlled trials with the relativism of qualitative approaches. It is concluded that the use of realist strategies in combination with randomised controlled trials provides the most coherent solution to this quandary.

Fundamental patterns of knowing in nursing: the challenge of evidence-based practice

This article reconsiders the fundamental patterns of knowing in nursing in light of the challenge of narrow empirics in the form of evidence-based practice. Objections to the dominance of evidence-based practice are reviewed, and the reasons for it are examined. It is argued that it is partially the result of weaknesses in the alternative patterns of ethical, personal, and esthetic knowing, the ineffability of which compromises accountability. This ineffability can be countered only by introducing a wider form of empirics than countenanced by evidence-based practice into all patterns of knowing, to demonstrate their salience and to make their use in practice transparent.