What’s the Point of the Evidence Debate?
We have just published ahead of print an article that will be published in the first issue of 2014! The article is titled “Particularizing the General: Sustaining Theoretical Integrity in the Context of an Evidence-Based Practice Agenda” by Sally Thorne, PhD, RN, FAAN, FCAHS and Richard Sawatzky, PhD, RN. Dr. Thorne and Dr. Sawatzky have extended their discussion of the “evidence” debate with this message for ANS blog readers:
Although we realize that “the evidence debate” may seem like a tired topic for some readers, we think it remains one of the most important avenues through which nurses can find their grounding in why the philosophy of science really matters to our discipline. Health and public policy get made on the basis of a complex and highly
Sally Thorne, PhD, RN, FAAN, FCAHS
politicized combination of ideology and science. We tend to think about ideology as if it exists in the world of “the other” and not in our own disciplinary knowledge. And yet, we must recognize that nursing has always been driven by so much more than just empirical science or philosophy, even if we sometimes struggle with how to name, conceptualize and justify those other forms of knowledge that influence our practice.
For us, the history of theoretical and philosophical knowledge-building in nursing is quite fascinating. Although it has taken a lot of twists and turns along the way (some of them sufficiently awkward as to be downright embarrassing), once you clear away the “noise” and reflect on what many of the founding nurse theorists and scholars were struggling with, you realize that they were grappling with incredible complexities. The language they used was sometimes a bit convoluted or misleading, and the competitiveness among the individual theorists and their disciples was at times unseemly. Nevertheless they were trying to work out ways of conceptualizing the rather marvelous constellation of intellectual and behavioral competencies that characterize the practice of nursing when it is done at its best, in order that we could improve our capacity to help nurses achieve that.
Of course if nursing were derived from a simple skillset, then that theorizing and philosophizing would have been
Richard Sawatzky, PhD, RN
easy. But it is not. And that’s what makes the story so fascinating. Patients are complex and adaptive, and so are we. The social and ideational worlds within which people experience health and illness are dynamic, multilayered, and fraught with uncertainties and complexities. The thinking nurse – that nurse we refer to as “expert” within his or her population group or setting – is always skillfully navigating that great chasm between science (which represents the general past) and context (which represents the particular moment), not to mention looking forward to considerations of possible implications for the future.
In re-entering the “evidence debate” in this manner, we wanted to juxtapose ideas about how we make sense of knowledge that comes from certain kinds of formally derived scientific processes with those that have to do with nursing’s inherent interest in the individual case. We believe that the trend towards standardized practice in health care during recent decades (e.g., reliance on general clinical practice guidelines) is increasingly at odds with notions of heterogeneity and individual differences (or “anti-standardization”), such as those prompted by field of personalized medicine. Just as many forms of medical management are moving away from population-based science (i.e., reliance on population averages) toward novel targeted and individualized therapies arising from genomics, proteomics and pharmacogenomics, we believe that nurses will need systems and structures through which to focus and strengthen individualized care and patient-centered approaches. These are not simply vague abstractions, but complex and challenging dimensions of the intellectual approach that nurses must always bring to their practice.
So for us, it seems useful to really push nurses toward clarity in what does and does not constitute evidence in the conventional sense. Slippage with how we frame the basis of what we think we know will only serve to discredit our profession as a credible contributor to the larger world that is wrestling with these evolving ideas. We are concerned that the tendency to reconceptualize certain forms of knowledge as “evidence,” in an attempt to obtain credibility, will not serve the nursing well. Nursing practice and theories are unavoidably influenced by many valuable forms of nursing knowledge that do not necessarily conform to conventional notions of “evidence.” Rather than “branding” all nursing knowledge as “evidence,” nurses are challenged to articulate what these “non-evidential” forms of knowledge are and what the basis is of their justification. We want to remobilize an enthusiasm for why nurses ought to care about the nursing theory world by bringing into focus the relevance that disciplinary thought has in the larger world of contested practices and influence upon futures.
We keep returning to this idea that the dialectic between the general and the particular is really the essential element in the uniqueness of nursing knowledge, our defining characteristic, the idea best captures what we are. As we continue to develop our collective expertise and wisdom with regard to evidence generation and interpretation – figuring out how we learn about the patients of the future through systematic and rigorous exploration of the past – it will be imperative that we not forget the “artform” of individualized holistic care, enacting relational practice, and taking an intersectional lens on the social determinants that may be shaping the health and illness experience of the patient who is before us in the moment.
Thanks for taking this journey with us, and we look forward to a lively debate!
You can download this article at no charge now on the ANS web site! Get it, read it, and come back here to engage in this very important, and interesting debate!
ANS: Advances in Nursing Science Blog 
First, I have to say that the article laid out both sides of the debate extremely well. My initial response has been a knee-jerk reaction where I was once again so incensed by argument of the superiority of empirical evidence. I appreciate the review of Carter’s ways of knowing and how we, as a profession have ridden the slippery slope of evidentiary claims; especially in the areas of clinical evidence. I know it doesn’t matter how much we rail against the unfairness of how the scientific community holds to the view of RTCs as being the “gold standard” to help prove evidence-based practice (EBP) and that we as a profession have to ‘get with the program’ by traveling the road of gathering general information (evidence) and imposing it onto the specific, and then we as a profession should get some “bonus points’ for the validity of our practice. However, as you have noted, this doesn’t always work.Foundational to most practicing nurses, we view the patient as our primary source of knowledge on how to care for them. We gauge their responses to nursing care when we note response shifts to nursing interventions and measure the therapeutic relationship we’ve engaged in. The goals of holistic care are also not far from our minds as well.The point was also made that due to ethical considerations, RTCs are not always an appropriate avenue to prove nursing EBP and so the profession has attempted (and not always elegantly) to find ways to demonstrate strong scientific processes. As I reflect on my practice, I see that it is very much an inductive process to which I adhere because of my beliefs and values of providing patient-centered care. I feel that many of these beliefs have to do with the training I received at university which help form and embed these beliefs into my practice. It has been only after several years after graduation that I’ve been challenged to re frame my approach to care. EBP was only just beginning to be mentioned of during the latter years of my training (1997-2002). My world view as a First Nations person was not oriented towards the empirical and I had to transform several schemas in my mind to get through the nursing program.Traditional ways of knowing were not part of the professional discourse at the time and I thought I had to abandon them to truly succeed in my chosen profession. I connected aesthetic knowing or intuitive knowing with my ideas of traditional knowing more formally later on as I gained nursing experience. My graduate training has had me searching for ways to demonstrate strong evidence for my contextual practice. While I now acknowledge the need for the profession to demonstrate with clarity and rigor in their evidence base, it still goes against the grain to approach my practice in a deductive manner. Therapeutic use of self within the moment of practice holds strong because I have an awareness that what I bring into the interaction; my nursing experience, emotional intelligence, scientific knowledge about their condition, all come together to produce the ‘nursing practice moment’ that produces a physiological response to care and this is not always easy to empirically measure. Indeed, it is hard to put a premium on producing this knowledge empirically when there are other scientific ways to do so, but these are down the EBP ladder of scientific proofs. I would imagine that it is the task of nursing education programs to continue to refine how they teach the importance of EBP while keeping the values of the “particular” when they are molding the new generation of nursing minds. Now this a tangent off of this topic, but please indulge me. I believe that nursing should be a part of the STEMS programs because of its roots in the scientific process and its strength in physiological sciences but because the “traditional scientific” world adheres to certain criterion where logic and empirical knowledge are the benchmarks of entrance, this door has been closed. That being said, should there emerge a way in which our proofs gain scientific validity that opens this door, nursing would be better positioned to host new ways expanding our influence in the non-nursing world. This is all I have time for today but I do look forward to continued engagement in this debate. Thank you.
Thank you for these very interesting reflections. In my experience, it is not so much the scientific community that upholds an exclusively empirical perspective of evidence-based practice. David Sackett’s definition of evidence-based practice places the patient’s values and clinical expertise right alongside with empirical evidence. And the many definitions of evidence-based practice in nursing similarly emphasize the importance of placing the patient at the center, incorporating professional expertise, and drawing on a rich and diverse body of evidence informed by multiple epistemological perspectives. Take for instance the definition offered by Alan Pearson from the Joanna Briggs Institute who asserts that, in addition to evidence of effectiveness, we also need evidence of appropriateness, meaningfulness, and feasibility, which requires drawing on a range of research approaches (including the full range of both qualitative and quantitative methods). There is good hope that few people within the scientific community believe that health care can and should only be determined by only one particular form of evidence that trumps everything else.
The problem, I believe, lies in the simplistic uptake of the evidence-based practice imperative and the uncritical application of knowledge that is derived from laws of averages and simplistic frequentist notions of statistical inference and hypothesis testing to the complex world of health services and nursing care provision. I recommend reading the work of Gerd Gigerenzer who has spent many years studying processes of decision making and the use of statistical information in health care. We must recognize the unique needs of people and groups within a diverse and heterogeneous world. Here too, I believe there is reason for good hope. The way in which evidence is constructed and taken up is changing dramatically. However, while this change is taking place, there is a risk of losing the notion of “evidence” altogether when particular forms of knowledge are put forward as if they are of the same nature as that which has been defined as “evidence”. When, in an attempt to be seen as credible, other forms of knowledge are asserted as evidence, there is a risk that very nature and distinctiveness of that knowledge is lost. It seems that the notion of “clinical evidence” may be a risk of exemplifying this mistake. There is no real need to define clinical expertise and experience as evidence in order to justify its fundamental importance and value in nursing. And, in doing so, there may be a risk of undermining exactly what clinical expertise and experience is all about. The same argument holds for other forms of knowledge, including values, beliefs and ideologies that inevitably influence health services and nursing care delivery. The challenge lies in valuing the full scope of human knowledge and figuring out how the different forms of knowledge relate to the nursing care we provide. Our paper, in part, seeks to address this concern.
Thanks again for sharing your thoughtful perspectives.
Kathleen,
I sincerely appreciate the thoughtfulness of your response, and the excellent points you have made. As you have so beautifully expressed it, uncritical adherence that which takes the form of deductively derived evidence as the main driver of practice decisions does seem entirely inconsistent with a nursing ethos. I think that the argument we were hoping to convey is that, while responsible nurses must be aware of that which is considered the current “empirical evidence” in their fields, their understanding of the inherent attributes (and limits) of that science also features strongly into their informed decision making. And those other knowledge forms associated with what one might creatively term “traditional knowing” of the discipline should never be undervalued or simply assumed. Your reference to this epistemological orientation in parallel with the First Nations perspective you have used to approach your own professional nursing practice really captures and illuminates the idea so beautifully, and I thank you for that.
I also totally agree with your conclusion that we need to continue to find ways to ensure that “our proofs gain scientific validity” in this emerging world. For me, this will remain an important ideal. As long as each new generation of nursing scholars remains open to immersion in the study of our theoretical and philosophical disciplinary tradition, I am confident that we will not lose sight of our “indigenous nursing knowledge” (in the fullest sense of the term) amidst the pressure to embrace the benefits of best evidence.
Thanks for being willing to put your thoughts out into the universe in this way. I know they will stimulate great dialogue!
I am delighted to have this article in ANS, and thrilled with the start of this dialogue! I just read a post on the “Scholarly Kitchen” that relates to the debate in this article – but in the publishing world. (see http://scholarlykitchen.sspnet.org/2013/12/13/prints-retreat-are-the-new-metrics-of-online-actually-devaluing-publications/) In this post “chef” Kent Anderson focuses on the move at “New York” magazine to reduce the frequency of the print magazine in favor of online publishing – a move that is closely connected to the “evidence” metrics around publishing. He makes a case that there are many other “value” metrics that are vital to publishing, but that are not easily measurable. I am disturbed by his conclusion that we are headed to a reality where only the numbers will drive the future. Yes, we are facing this in nursing and health care as well, so this debate we are having here is vital if we hope to shape a future in which we have the courage to do that which is not easy, but vital to meaningful, effective human health and well-being!
It is a great article and leads to all sorts of interesting tangents.
Unfortunately I could go on about this topic for hours because it is intimately related to my favorite topic – capitation-like health care finance mechanisms.
Both protocol driven care and capitation payments are attempts to substitute the unknown optimal treatments (costs) for the care of individual patients with some sort of pre-planned treatments (capitation payments).
They are both rationalized on the quicksand of statistical flaws that emerge when people fail to distinguish between random observations and average values, coupled with a similar failure to consider the impact of the non-linear utility functions associated with the magnitudes of the errors between the treatment protocol (capitation payment) and the optimal treatment needed by the patient (provider’s cost to optimally treat the patient).
Far from being gold standards, randomized clinical trials (capitation-like payment mechanisms) fail because the risks associated with the utility of errors is far greater than assumed and inadequately appreciated by designers, proponents and users of treatment protocols (insurance risk transferring organizations). This failure to appreciate the length, depth and width of the chasms between protocols (capitation payments) and patients’ needs (providers’ costs) that create the problems we observe.
Unfortunately, the virtues of randomized clinical trials (and capitated payment systems) are superior, in general, to the virtues of encouraging each nurse or physician to use their own personal knowledge to make decisions about patient care because historically this has led to errors between needed care and offered care that dwarf those that occur because of misguided reliance on randomized clinical trials and capitation-financed health care.
One may seriously question whether a dose of Insulin is too large, or too small, by 10% and most patients will survive the encounter. But if the patient is diabetic with a blood sugar of 198 and one nurse uses the prescribed sliding scale to give the patient a dose of insulin and another nurse thinks the best intervention is an energy healing session, the patient is unlikely to suffer harm from the insulin and great harm from the energy healing.
A core virtue of a sliding scale insulin protocol is that it limits the error likely to be made in responding to the patient’s condition. Personal knowledge, as a guide to professional practice, has no such error minimization effect, leading to the potential for errors of extraordinary magnitude.
Capitation, much as I dislike it theoretically and practically, has a similar virtue, making it difficult for any health care facility to hire and retain nurses who would substitute energy healing for insulin for diabetic patients because the facility’s capitation payment will not cover the cost of such care.
Nursing need not swallow randomized clinical trials as though they were delivered by God(dess). RCTs are generally based on very small samples with exceedingly constrained enrollment standards that are unlike the clinical situations in which the derived treatment protocols will be used. Subjects are observed for very short periods of time and the results are analyzed over very short periods of time.
As well, if we read the reports of consulting statisticians we see virtually no references to causality, dozens of statements that make it clear that the statistician does not endorse any extrapolation from the sampled subjects to a larger population and repeated efforts on the part of the statistician to caution against overzealous reliance on the data, the analysis or the conclusions. What you do not see in statistician’s reports are statements that suggest that the data confirm the alternative hypotheses and disclaimers about the meanings to be read into any rejections of null hypotheses.
Actuaries, on the other hand, rarely exercise such cautions, happily producing insurance premium rates based on the sparsest of data and with little sound theoretical footing. That is part of the reason capitation-like health care finance mechanisms are so destructive because not only are they not based on solid theoretical or empirical footing but there is a lack of circumspection about their use.
Just as it is dangerous to substitute energy healing for insulin, it is even more dangerous to substitute a capitation payment of $6,000 for a 60 day episode of home health nursing for the actual costs of providing excellent home health nursing. There is a natural tendency to minimize the needs of those whose needs are great and to extend additional care to those with the least need – precisely the impact that the Home Health Nursing Prospective Payment System has.
So, this isn’t so much an issue of whether quantitative research, randomized clinical trials or more personal knowledge is a better guide for nursing care, but a question of the degree to which errors will be made in caring and how important the consequences of those errors will be. Qualitative studies and personal knowledge tend not to provide any notion at all of how much error may result if they are employed, while quantitative studies at least attempt to measure the gap between average levels of care and the most likely outcomes.
Thank you Drs Thorne and Sawatzky for this work! So many difficult concepts articulated so clearly. I am a second career nurse and just completed my doctorate in nursing. I have a question about the “knowledge forms associated with what one might creatively term “traditional knowing” of the discipline”, which should never be “undervalued or simply assumed”. The authors challenge nurses to “articulate what these ‘non-evidential’ forms of knowledge are”. The question is, if we could identify orientations and approaches that enable us to “make visible” these forms of knowing, would that not (a) help to better articulate and clarify “non evidential” forms of knowledge but also (b) actually produce actionable empirical evidence? I am learning about practice theory, which focuses on “dynamics, relations and enactment” (Feldman & Orlikowski, 2011). According to Feldman and Orlikowski, practices (such as nursing practice) have dynamics that cycle between actions people take, the ideas they hold in relation to these practices, and the outcomes they observe based on their actions. I believe this sounds a lot like the work nurses do in obtaining ‘non-evidential’ forms of knowledge and acting on them in practice. Orienting nursing practice in this way might allow us to “capture” this process in action (for example, studying the routines of nursing practice), and bring it to the level of dialogue (rather than assumption) and possibly even to the level of ‘evidence’ in support of the concept of “traditional” forms of nursing knowledge. Thank you again for your article.
I don’t disagree that these are highly important forms of knowledge, Miriam, but my position would be that they are something different in nature from that highly specific kind of population-based entity we are intending to reference when we use “evidence language” to justify it. One challenge is that many nurses have obtained education in the substantive field without having a solid philosophical disciplinary grounding, and have not had the opportunity to critically reflect on the world of “ideas” that structure thinking in the discipline. It may no longer be in vogue in many schools to study “nursing theory,” and indeed that model-building movement did run into numerous problems as various theorists attempted to position their work. However, it did provide a beginning window into the philosophizing that is really strengthening the discipline today.
The primary aspect those theorists were wrestling with was the way in which the nursing mind conceptualizes the person within any clinical situation, drawing on a universe of possible knowledge forms to find the best approach for the moment. Formal evidence plays a significant role in that, and ignorance of the prevailing evidence is never justifiable. But excellent nursing inevitably and always involves sensitive attention to the individual within his or her particular context, which may imply departures from prevailing evidence. To get there, nurses draw on numerous knowledge forms, including Carper’s seminar ways of knowing, clinical pattern recognition, and even that form of knowledge we sometimes call “intuition” ( likely because it feels so inarticulable –but that is an “informed intuition” we are referring to, in that the bystander’s intuition would have a different valence in our determining an intervention than would that of the experienced nurse). And so being able to find language to clearly delineate between different knowledges — each with a different nature in influencing the reasoning we take when we approach each unique and particular patient phenomenon — is incredibly using in helping us attain clarity and precision – to explicitly defend the logic of our actions. I do worry about nurses who have “bits” of substantive knowledge (such as pieces of evidence) without an coherent organizing framework within which to logically reason how and when to make use of them. And that “how-and-when” is what nursing theory and philosophy have been wrestling with over the ages. In the current world, in which we have marvelous philosophical options, and new “standpoints” from which to critically view our disciplinary thought (like complexity theory), it seems increasingly useful to have a cadre of leaders with sufficient curiosity about “how ideas work” to lead the discipline forward. To me, this evidence-based nursing debate is an important philosophical debate, seeking real clarity among us as to what the nature of our knowledge entails, and how we develop the capacity to use it well. It is both an ontological issue, in the sense of the nature of nursing, and an epistemological one, in the sense of how we know what we know.
So I very much agree with you, Miriam, that all forms of knowledge are worth thinking about. There is much to be gained by forming reasoned arguments about how and when each applies, as well as critically reflecting on where each of them could mislead us. We have a sense, nowadays, about how to use evidence in practice. We are somewhat less clear about how we use the iterative understandings that derive from the praxis of practice. Applying them in the same way we use evidence is inherently problematic – hence the need to make that sharp distinction in terminology. But with great nurses asking great questions, and being willing to enter into the philosophical fray, we’ll get there!