Style, substance, Newspeak 'and all that': a commentary on Murray et al. (2007) and an open challenge to Goldacre and other 'offended' apologists for EBM

"They just know": the epistemological politics of "evidence-based" non-formal education

Community education and outreach programs should be evidence-based. This dictum seems at once warranted, welcome, and slightly platitudinous. However, the "evidence-based" movement's more narrow definition of evidence--privileging randomized controlled trials as the "gold standard"--has fomented much debate. Such debate, though insightful, often lacks grounding in actual practice. To address that lack, the purpose of the study presented in this paper was to examine what actually happens, in practice, when people support the implementation of evidence-based programs (EBPs) or engage in related efforts to make non-formal education more "evidence-based." Focusing on three cases--two adolescent sexual health projects (one in the United States and one in Kenya) and one more general youth development organization--I used qualitative methods to address the questions: (1) How is evidence-based program and evidence-based practice work actually practiced? (2) What perspectives and assumptions about what non-formal education is are manifested through that work? and (3) What conflicts and tensions emerge through that work related to those perspectives and assumptions? Informed by theoretical perspectives on the intersection of science, expertise, and democracy, I conclude that the current dominant approach to making non-formal education more evidence-based by way of EBPs is seriously flawed.

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.

Reason, reality and objectivity--shared dogmas and distortions in the way both 'scientistic' and 'postmodern' commentators frame the EBM debate

Both defenders and certain critics of evidence-based medicine (EBM) share philosophical commitments - assumptions about the meaning of and relationship between such fundamental concepts as 'objectivity', 'subjectivity' and 'rationality'- that frame the debate between them. Critics need to be particularly careful in analysing their own philosophical commitments. Ironically, failure to do so has led some to ground their rejection of EBM in philosophical theses that are less clear and/or more contentious than the reasonable conclusions they wish to defend. There is no need to label 'objectivity' a 'myth' or 'scientific method' an 'illusion' in order to identify what is wrong in EBM. Such strategies play into the hands of EBM dogmatists, allowing them to continue to position themselves as the defenders of 'science' and 'reason'.

Towards an ethics of authentic practice

This essay asks how we might best elaborate an ethics of authentic practice. Will we be able to agree on a set of shared terms through which ethical practice will be understood? How will we define ethics and the subject's relation to authoritative structures of power and knowledge? We begin by further clarifying our critique of evidence-based medicine (EBM), reflecting on the intimate relation between theory and practice. We challenge the charge that our position amounts to no more than 'subjectivism' and 'antiauthoritarian' theory. We argue that an ethical practice ought to question the authority of EBM without falling into the trap of dogmatic antiauthoritarianism. In this, we take up the work of Hannah Arendt, who offers terms to help understand our difficult political relation to authority in an authentic ethical practice. We continue with a discussion of Michel Foucault's use of 'free speech' or parrhesia, which he adopts from Ancient Greek philosophy. Foucault demonstrates that authentic ethical practice demands that we 'speak truth to power.' We conclude with a consideration of recent biotechnologies, and suggest that these biomedical practices force us to re-evaluate our theoretical understanding of the ethical subject. We believe that we are at a crucial juncture: we must develop an ethics of authentic practice that will be commensurable with new and emergent biomedical subjectivities.