© 2003 Blackwell Publishing Ltd

Nursing Inquiry 2003; 10(3): 159–160

R e s p o n s e

Blackwell Publishing Ltd.

Response to Angus Forbes:Alternative perspectives

TRUTH AND THE DEATH OF INTENTION

It is a rare treat to have one’s work engaged in published crit-ical discussion. The production of nursing scholarship couldwell do with more of such activity. That said, such an eventalso foregrounds for me how perilous the hermeneutic jour-ney is; an author’s ideas/words and their intent are seldomreceived by others with the effects one had anticipated orhoped for during their preparation. Indeed, my interlocutorconfirms how amazing it is that we ever manage to relate toothers when the tensions between what is said and what ismeant, what is sent and what is received, are subject toalmost infinite perversion and permutation along the way.As Nietzsche reminds us: ‘there are no facts, only interpreta-tions!’ (Chambers 1994, 25).

I don’t believe I have ‘thrown the baby [evidence basedpractice (EBP)] out with the bath water’ (Forbes 2003, 156)(its ideological and philosophical scaffolds). Neither have Imerely ‘dismissed EBP as positivist or empiricist’ thus failingto distinguish between the ‘nature and methods of EBP andthe way in which it has become politicized and professional-ized’ (156). On the contrary, I have tried to show how EBPgenerates the very controversy it has because the natureand methods of EBP are inextricably interwoven with theway it has become politicized and professionalized. Inattempting to highlight the effects of certain powerful formsof rationality on the phenomenon of EBP, I have sought tocomplexify rather than simplify the debate.

Clearly the arguments around the relationship betweenEBP and economic rationalism have resonated morestrongly with my colleague than its imbrication with positiv-ism, empiricism and pragmatism. My intent, though, was tobegin to outline how it is more than simply one form of con-temporary rationality that enables EBP to come to expres-sion in the ways and the times in which it has. Rather, it isthe combined effects of the four forms of rationality whichallow for both the methods and objectives of EBP to be con-structed as they are while at the same moment producingthe particular effects of knowledge and power they do interms of who sells and who buys the idea of EBP in the firstplace.

Forbes is right to ask what the alternatives are and hesuggests that nursing and medicine are talking of ‘narrative-based’ approaches (157) to evidence. I would argue thatcause is well advanced in nursing (and to a lesser extent inmedicine) and would strongly argue in favour of pursuingsuch a line of thought even more vigorously than we havethus far. It seems to me, however, that because EBP enjoysthe purchase it has on the epistemological and politicalimaginations of the two professions, little room is left foralternatives. In other words, EBP has already achieved a sortof ‘permanent presence’ (despite its detractors’ objections)in the minds of policy-makers and practitioners alike. Thisrenders it much less susceptible to destruction than mightotherwise be the case. All of which is to agree with Forbesrather than the obverse, when he states:

The tricky bit with EBP is to ensure that nurses are in con-trol of EBP using it to develop nursing rather than beingcontrolled by it, working as technical administrators alien-ated from the EBP process. (157).

Let me assure Dr Forbes that EBP is virtually nowhere tobe seen or heard in contemporary clinical practice; it isa phenomenon, at least in Australia, largely experiencedin the nursing academy (not to forget, the healthcarebureaucracy). Clinical nurses at the bedside have barely, ifat all, been involved in its invention, its application andcertainly not its evaluation. As Miles et al. (2003) note in areview of current thinking in the EBP healthcare debate(and their comment resonates with the question I posed atthe end of my paper ‘Why evidence-based practice now?: apolemic’):

we consider it eminently reasonable to demand evidencethat [EBP] does more good than harm by subjecting itselfto the well-established requirements of scientific testingand medical ethics which, ironically, it itself has been so tri-umphalist in defending, but which it itself has uniquelyescaped. Surely the time has come for this dramatic irony tobe fully appreciated and properly addressed? (106).

REFERENCES

Chambers I. 1994. Migrant landscapes. In Migrancy, culture,identity, 9–48. London: Routledge.

K Walker

160 © 2003 Blackwell Publishing Ltd, Nursing Inquiry 10(3), 159–160

Forbes A. 2003. Alternative perspectives. Nursing Inquiry.10(3): 156–158.

Miles A, JE Grey, A Polychronis, N Price and C. Melchiorri. 2003.Current thinking in the evidence-based healthcare debate.Journal of Evaluation in Clinical Practice 9(2): 95–109.

Walker K. 2003. Why evidence-based practice now?: apolemic. Nursing Inquiry 10(3): 145–155.

Kim WalkerSt Vincent’s Private Hospital

Darlinghurst, New South Wales