Why evidence-based practice now?: a polemic

© 2003 Blackwell Publishing Ltd

Nursing Inquiry 2003; 10(3): 145–155

F e a t u r e

Why evidence-based practice now?:a polemic1

Kim WalkerSt Vincent’s Private Hospital, Darlinghurst, New South Wales, Australia

Accepted for publication 25 May 2003

WALKER K. Nursing Inquiry 2003; 10: 145–155 Why evidence-based practice now?: a polemicEvidence-based practice (EBP) first appeared on the healthcare horizon just over a decade ago. In 2003 its presence has inten-sified and extended beyond its initial relation to medicine embracing as it does now, nursing and the allied health disciplines.In this paper, I contend that its appearance and subsequent growth and development are the effects of potent ‘regimes oftruth’, four of which bear the names: positivism, empiricism, pragmatism and economic rationalism. My aim is to show howEBP generates the controversy it does because its nature and methods are inextricably interwoven with the way it has becomepoliticised and professionalised. This exegesis is an attempt to outline how the combined effects of the four forms of ration-ality mentioned above allow for both the methods and objectives of EBP to be constructed as they are, while at the samemoment producing the particular effects of knowledge and power in terms of who sells and who buys the idea of EBP in theculture of contemporary healthcare.

Key words: best practice, discourse, evidence based practice, rationality, regime of truth.

Each society has its regime of truth, its ‘general politics’ oftruth: that is, the types of discourse which it accepts andmakes function as true; the mechanisms and instanceswhich enable one to distinguish true and false statements,the means by which each is sanctioned; the techniques andprocedures accorded value in the acquisition of truth; thestatus of those who are charged with saying what counts astrue (Foucault 1980, 131).

TOWARD A ‘GENERAL POLITICS’ OF TRUTH

Attending the formal opening colloquium of the JoannaBriggs Centre for Evidence Based Nursing and Midwifery inAdelaide, Australia, mid 1997, I recall asking myself: whyevidence-based practice now? The profession has longneeded to embrace more pedagogically progressive methodsof teaching, learning and developing knowledge of andfor the discipline than our history has generally affordedus. Consequently, I had no real problem with the idea ofevidence-based practice (EBP). But it was the relatively precip-

itous arrival of EBP on nursing’s agenda for the futurethat aroused my curiosity. What follows, in keeping with theextended citation from Foucault above, is an attempt tothink ‘politically’ and philosophically about how and whyEBP comes to expression in the ways that it does. More par-ticularly, I ask: what effects does it produce in terms of a cer-tain urgency to embrace its seemingly compelling agendain the times in which we find ourselves? The following is aprovisional and highly partial (in both senses of the word)critique of the relatively unquestioned authority claimed forEBP by the proselytisers of the movement; it is designed tobeg more questions than to locate answers (in the hope thatfuture conversations will be forthcoming about the merits,or otherwise, of EBP for nursing).

In particular, I pick up a certain line of thought andextend some important arguments advanced by Traynor(1999) in a paper which explores similar territory to that youare about to discover. Traynor (1999) develops a rigorous andcritical examination of the tensions between evidence-basedpractice understood as a relatively neutral and disinterested

Correspondence: Practice and Development Research Coordinator, St Vincent’sPrivate Hospital, 406 Victoria Street, Darlinghurst, New South Wales, 2010Australia.E-mail: <[email protected]> 1 A controversial argument or discussion. Concise Oxford English Dictionary.

K Walker

146 © 2003 Blackwell Publishing Ltd, Nursing Inquiry 10(3), 145–155

system for the dissemination of scientific knowledge tothe healthcare professional community and its (often unac-knowledged) deeply ideological function as a set of ideasand practices designed to persuade and seduce specificaudiences in pursuit of particular vested interests. Theseideas and practices both support and are buttressed bygenerally unspoken ‘truths’ about the nature of scientificknowledge, the rhetorical structures that carry such knowl-edge, the differences among the various health professionsand their often essentialised and dichotomised relationswith each other. It is how each of these discursive structuresand processes position the practitioners of and ambassadorsfor EBP as authoritative and bearers of a certain truth (at theexpense of others who might not want to be complicit withthem) with which we need to be concerned.

In this paper I suggest there are potent ‘regimes of truth’that support Traynor’s often confronting analysis; to openthem to interrogation might just help us advance a seriouschallenge to the inexorable momentum EBP has acquired(Jennings and Loan 2001, 125). It is a call to pause and to re-think how and why we are investing energy and resources inits development when perhaps these might be not as wellplaced or guided as they should be. Let me add here that,contra Closs and Cheater (1999, 13), this text does notattempt to resuscitate ‘that tiresome old chestnut the quali-tative/quantitative divide’. While it might seem like it attimes, my point is that while ‘some antagonism toward EBN[evidence-based nursing] seems to derive from viewing it asan unwanted extension of the positivist tradition’ (Closs andCheater 1999, 13), the position I cast here is that EBP farfrom being simply an ‘unwanted extension’ of such a tradi-tion, is profoundly imbricated in positivist philosophy andpractice. This positioning allows it to mute any critique of itssignificance (which is going decidedly further than a luke-warm ‘antagonism’). A caveat: one reviewer of this manu-script suggested I make EBP something of a caricature in thistext. While I don’t think it was intended this way, I’ll take thisas a compliment in the sense that caricatures are often usedfor political intent deliberately to draw attention to an issueor a character in such a way as to provoke comment (if notlaughter). This is precisely what a polemic has in mind too,of course (and why such a genre is generally disparagedamong ‘proper’ academics). So with my cards firmly on thetable, read on if you’ve a will!

EBP: flavour of the minute

The profession has generally embraced EBP wholeheartedly(Pearson et al. 1997; French 1998; Regan 1998; Stetler et al.1998; Roberts 1998; Goode 1999; Lang 1999; Street 2001;

Nagy et al. 2001; Parker 2002;) but a growing numberregard it with caution (Kitson 1997; Rafferty in Naish 1997;Kitson, Harvey and McCormack 1998; Salvage 1998; French1999; Closs and Cheater 1999; Bonell 1999; Traynor 1999;McCormack et al. 2002). Few would likely share my moreradical position that it is the last thing we need to be indulg-ing ourselves with at the moment given the global crisis ofsurvival the profession now confronts. As Jackson, Mannixand Daly (2001, 163) note well: ‘Problems with recruitment,retention and an ageing workforce must be placed on thetop of the professional agenda … Nursing and nurses arefacing unprecedented challenges and pressures in the work-place … The nursing workplace has disturbingly high levelsof occupational violence, and many nurses operate within aculture of blame and scapegoating’. Nay and Pearson (2001,38) paint a slightly different but no less bleak picture:

as the 21st century begins, yet another workforce shortagelooms and the debate on who should be nurses; how nursesshould be educated; and what constitutes the legitimaterole of various levels of nurses still rages despite trying toevade a problem that is unlikely to go away.

Not a good time to be fiddling around trying to findevidence for our work and of our worth while the very pro-fession itself faces extinction.

But it seems even in the midst of such a pervasive culturalmalignancy we are confronted with EBP, and deal with itwe must (cf. Forbes and Griffiths 2002, 143). Not only this,however, for EBP is inextricably linked with another potentcatchphrase in these early days of the 21st century: ‘bestpractice’ (BP). The link between EBP and BP is important.As Pearson et al. (1997, 4) tell us:

[d]evelopments in health care in most Westernised coun-tries over the past 10 years have been driven by a desire tocontain costs and to increase effectiveness. The introduc-tion of the notion ‘best practice’ relates closely to this focuson clinical and cost effectiveness and ‘best practice’ is beingincreasingly linked to the need to base practice on the bestavailable evidence.

Clearly, the assumption is that evidence-based practicewill result in best practice. This seduction by superlatives(best evidence, best practice, best quality) is surely a contem-porary expression of Enlightenment values of progress forthe betterment of humankind; we are forever compelled toimprove on and refine the strategies and techniques ofadvancement and merit in all human endeavours (Holmes2001). All of which is not necessarily bad, but as Foucault(1984) would warn, it could be dangerous. The history ofmodernity’s worst excesses conducted in the names ofprogress collectively scar the psyches of many across theglobe. It is a central tenet of modernity’s critics that we must

Evidence-based practice

© 2003 Blackwell Publishing Ltd, Nursing Inquiry 10(3), 145–155 147

be ever mindful of the potential for every purportedlyenlightening or empowering new idea to undermine its ownpotential (Lather 1991; Giroux and McLaren 1994). Witnessthe ecological crisis borne of humankind’s need to increasethe production and consumption of non-renewable energysources to maintain the wealth of the so-called first worldcountries; the ‘taming’ of nature by technology and industryto enliven humanity’s existence. These are but two exem-plars of modernity’s obsession with progress and the activi-ties it spawns, run horribly amuck.

A SOCIETY’S POLITICS OF TRUTH: THE TYPES OF DISCOURSE IT ACCEPTS AND MAKES

FUNCTION AS TRUE

We find ourselves confronting the juggernaut of EBP, I pro-pose, because a concatenation of discursive forces propelsus in this direction. Out times are deeply riven by certain‘regimes of truth’ (Foucault 1980), as the citation which her-alds this paper asserts. Four such regimes take the names,economic rationalism, empiricism, positivism and pragmatism.Operating in concert, it seems to me these epistemic framesof reference mutually authorise a certain version of theworld that allows for an ideologically charged movementsuch as EBP (Traynor 1999; Kitson 2002) to come to expres-sion; not only in the ways that it does, but, more particularly,in the times that it has and with the effects it produces. Thisis, I guess, a curious and incomplete exegesis that ‘shows asmuch as it explains, plays as much as it argues, seduces asmuch as it demonstrates, conceals as much as it reveals’(Marsh, West and Caputo 1992, 12).

The status of those who are charged with saying what counts as true

Asking ‘why evidence-based practice now?’ urged me to turnto what is unarguably the seminal publication of the EBPmovement as it has been driven, specifically, by the disciplineof medicine. In relation to the culture of contemporary health-care, we really ought to be talking about evidence-basedmedicine because it is in medicine’s footsteps that otherssuch as nursing, have followed (Pearson2 et al. 1997, 3;

Jennings and Loan 2001, 122; Winch, Creedy and Chaboyer2002, 156).

As Sackett and colleagues note ‘[e]vidence-based medi-cine[’s] … philosophical origins extend back to mid-19thcentury Paris and earlier’ (Sackett et al. 1997, 2). They fail toexplain, however, why the phenomenon of evidence-basedmedicine (EBM) has come to appear and dominate in theways that it has. They imply that insofar as medicine haspractised in this way since the mid-19th century one wouldexpect contemporary practitioners to follow in their fore-bears’ footsteps; perhaps, but not without some help.

Back in 1979 Cochrane3 announced ‘[it] is surely a greatcriticism of [the medical] profession that we have not organ-ized a critical summary by specialty or subspecialty adaptedperiodically of all relevant randomised controlled trials’ (inPearson 1997, 2). It is especially worth noting he also arguedthat ‘since resources for health care are limited, they should beused effectively to provide care that has been shown, in validevaluations, to result in desirable outcomes; he also emphasisedthe importance of randomised controlled trials in providingreliable information on the effectiveness of medicalinterventions’ (in Pearson et al. 1997, 2). These assertionsare significant. They lean toward an acknowledgementthat the logic of economic rationalism informs and shapesthe development and movement of EBM as they alsoproclaim its positivist proclivities. As Closs and Cheater(1999, 11) remark:

The need to provide health care equitably and effectivelyfor the whole population, in a financially restricted climate,has provided the current impetus for [EBP] in Westernhealthcare systems … pressures on limited resources forhealth care are rising … further demands for healthcareresulting from the ‘consumerist movement’ during the last15 years or so have raised patients’ expectations of the qual-ity of health care to which they are entitled … An underly-ing assumption of [EBP] is that science based practice willtell us what the most successful and cost-effectiveapproaches to nursing care are. Then we will be in a posi-tion to provide best possible care at least possible cost in anenvironment of limited resources. This would make a greatdeal of sense.

Linking the idea of limited resources with their effectiveutilisation is a central axiom in economic rationalist theory;market forces dictate that limited resources demandprudent use if most are to benefit (or profit). Limiting the

2 Professor Alan Pearson is almost single-handedly responsible forinaugurating the EBP movement in nursing and midwifery in Australia (andindeed, now, across Australasia). His status as the first professor of nursingappointed in Australia is also significant in that he commands a very highprofile both here and internationally. The authority accrued to his status overthe years in part affords the profile of EBP greater currency and purchase onthe collective imagination of the profession, than might otherwise be the case.

3 Dr Archie Cochrane is, of course, the man whose name is now lent toperhaps the most prominent marker of the EBP movement , the CochraneCollaboration. Such a symbolic and material signifier of status and significanceaffords EBP enormous prestige and indeed medicine has often used its highprofile performers to accrue authority and legitimacy to its ideas and practicesin this (literally spectacular) way (see Jordana in Cooke and Wollen 1995,203–17).

K Walker


sources of acceptable evidence in this search for ‘valid eval-uation’ of effective health care to ‘relevant randomised con-trolled trials’ immediately positions Cochrane’s statement inthe discourse of ‘big science’ — the most venerable of positiv-ism’s various modes of inquiry.

If we conjoin the comments from Pearson et al. (1997)and Closs and Cheater (1999) concerning the mountingpressure to embrace EBP and BP with Cochrane’s statementabove, then reading across these claims it is not difficult toappreciate how EBP quietly, almost imperceptibly, gathersauthority with such subtle, yet insistent, endorsements. Ofcourse, it is highly unlikely that a medical scientist/practi-tioner would actively promulgate economic rationalism asa force behind something as purportedly worthy as EBM.Medicine has long been congratulated (and applauded itself)for its principled stance in relation to ideals of altruism andthe betterment of humankind via the alleviation of sicknessand suffering.

The proponents of EBM could not afford to be seen tobe motivated by something as base as financial cost and theneed to contain such a cost, at least not overtly or explicitly.Salvage (1998) has argued a somewhat similar line ofthought in relation to EBP as a component of the clinicaleffectiveness agenda and R & D policy in the UK. She sug-gests that:

[t]he debate about public spending priorities, and rationingin health care, is being depoliticised as a means of foreclos-ing it … the R & D policy owes much to the value-for-moneyculture fostered by Thatcherism, which at its extreme regardsthat which cannot easily be measured as unnecessary orineffective’ (Salvage 1998, 413).

Even the most ardent altruist among the medical com-munity would have to acknowledge that medicine — as adiscipline and an indispensable practice — is not immuneany longer from considerations of shrinking budgets andlimited fiscal resources. It has to find another way then, ofshoring up and promoting the necessity of EBM and it is topositivism and empiricism that it turns. By association, then,economic rationality finds an ally in these two discursivefields (as we have just heard) and these three regimes areunited by another potent force, pragmatism (but more ofthis later).

The techniques and procedures accorded value in the acquisition of truth

Positivism and empiricism have received a modicum ofcritique in relation to nursing research and scholarship overthe last decade or so (Kim 1993; Chung and Nolan 1994;Horsefall 1995; Walker 1997a). Others might argue they have

been unfairly demonised as a result. However, I’m not evensure that we always share understandings about them asmuch we might. Definitions of such contested territory atleast offer common ground about what it is we think we arediscussing. Therefore, positivism for me embraces ‘the viewthat all true knowledge is scientific, in the sense of describ-ing the coexistence and succession of observable phenom-ena … positivism [in others words] is a scientifically orientedform of empiricism’ (Bullock, Stallybrass and Trombley1988, 669). Empiricism embodies the:

theory (1) that all concepts are derived from experience,i.e. that a linguistic expression can be significant only if it isassociated by rule with something that can be experienced,and (2) that all statements claiming to express knowledgedepend for their justification on experience (Quine inBullock, Stallybrass and Trombley 1988, 269).

The key terms in both definitions are science, observa-tion, justification and experience. Note how intertwinedeach of these doctrinal positions is in each other. Empiricismand positivism together forge perhaps the most formidableepistemic regime of truth since humanity’s time on earth.They certainly can lay claim to having created the founda-tions of modern knowledge and the structures and forceswhich operate on the basis of such knowledge and thetheory of truth which undergirds them. Empiricism andpositivism and their technologies of knowledge productioncollectively account for the ‘hard evidence’ from which weforge so many of our assumptions about and ways of operat-ing in and on the world. But as Gregson, Meal and Avis(2002, 25–6) have theorised recently, proponents of EBPand its various structures of authorisation and legitimationsuch as the systematic review and meta-analysis ‘are workingwith a particular conception of truth, a naive realist view thatis intuitively appealing but ultimately misleading’. By naiverealism we mean that the ‘truth’ of the knowledge generatedby empiricism’s and positivism’s essentially descriptive tech-niques of analysis — the systematic review and meta-analysis,see also Forbes and Griffiths (2002, 145) — is believed simplyto be reflected in the reality it purports to describe (in otherwords, knowledge (of reality) is ‘already there’ but needs theempiricists descriptive skills to give it a suitable name andthus pronounce the ‘truth of things’). Harari (2001, 729), amedical academic exploring the epistemological traditionsof science in medicine also argues that ‘“evidence-based”approaches are predicated on misplaced confidence in thepower of empiricist principles to determine what constitutesreliable knowledge. In other words, techniques of experimentand observation (e.g. clinical trials and other experimentaland quasi-experimental methods) alone are insufficient toconstruct our understandings of ‘reality’ which is decidedly



more complex and confounding than anything our experi-ence (the ‘evidence’) might tell us. Tonelli (1998, 1235) too,is concerned about the epistemological reliance on incorpo-rating evidence from clinical trials into medical practice. Hesuggests this requires a ‘specific kind of clinical reasoning, atype generally considered to be “scientific”, as it attempts toobjectively and deductively apply empirical knowledge tospecific cases’. Tonelli argues that this form of reasoning, aswell as the inevitable ‘hierarchies of knowledge’ it creates,produce both an epistemological and ethical ‘gap’ betweenresearch and practice and which EBM has only partiallyacknowledged and, accordingly, failed adequately, to address(Tonelli 2001).

This naïve realist version of truth, both carried and cer-tified by empiricism and positivism, posits that ‘knowledgeof a reality outside human invention is gained through theapplication of a rigorous, mathematically based methodof inquiry, science, which yields objective facts’ (Gregson,Meal and Avis 2002, 26). This objectivity sets at a distance therelationship between a knower (a subject) and the known(an object); this distance is merely a theoretical devicedesigned to create a sense of authority for the knowledge sogenerated because it cannot be contaminated by opinion,the messiness of conjecture, or the artifice of imagination ofa ‘subjective’ human. Hence we arrive at the ‘hard’ and ‘soft’data metaphor. We are, it seems, creatures who have littlefaith in our own capacity to know the world from the inti-macy of our involvement in it (soft knowledge). And yet innursing, we know that much of what works in practice is oftena profoundly embodied and equally often highly subjectiveset of knowledges that is not easily verified by empiricaltesting or even rational explanation (hard knowledge).However, such a binarism — hard vs. soft — is banal at best,obfuscating at worst (Walker 1995a,b; 1997b).

The mechanisms and instances which enable one to establish true and false statements, the

means by which each is sanctioned

Little effort is required to hear the underlying assumptionsand parameters of evidence-based practice lurking in thedefinitions of positivism and empiricism above. In the med-icalized version of EBP the randomised controlled trial istouted as the ‘gold standard’ methodologically speaking, foracquiring sound evidence in clinical interventions and forevaluating their effectiveness and efficiency (Sackett et al.1997). Of course, as Closs and Cheater (1999, 14–15) rightlynote, there are instances in the best evidence debate whenRCTs are either inappropriate as the ‘standard’ or whentheir design and conduct is flawed, thus leading to inade-

quate or even misleading forms of evidence. However, it isthrough the serial endorsement and re-endorsement ofscience as method that medicine has achieved, in part, its riseto the status it now enjoys (Seymour 1998). There are somehowever who, despite their allegiance to science and theirrecognition of its significance for medicine, now question:whether EBM limits or facilitates patient choice (Rogers2002); creates particular biases and misrepresents the evi-dence (Juni et al. 1999; Rosen and Teesson 2001; Hampton2002); oversimplifies the complexities of clinical care(Naylor 1995; Schriger 2000; Williams and Garner 2002);misrecognises the differences between ‘average’ patientscollected for large scale studies and far-from-average indivi-dual patients treated in real life medical practice (Asch andHershey 1995; Feinstein and Horowitz 1997; Sarasin 1999).Others also argue EBM compromises clinical freedom andmarginalises ‘social and individual values’ (Maynard 1997)and fails to provide specific guidance on effective interven-tions because systematic reviews sometimes reach ‘uncertainconclusions’ (Petticrew 2003, 756). All the above authorsacknowledge that EBM, nonetheless, has received enthusiasticendorsement from the medical community and ‘acquiredthe kind of sanctity often accorded to motherhood, home,and the flag’ (Feinstein and Horowitz 1997, 529).

I am suggesting then, to pick up the thread, that empir-icism and positivism collude (via their key stakeholdersand acolytes) with economic rationalism, a ‘large intellectualand political movement, encompassing a wide variety ofviews favouring a greater role for markets and a reduced rolefor government’ (Norton 1997). They do this in order toproduce truth effects in the world which make it rationalfor us to consider money as something of a ‘bottom line’ inclinical decision-making processes and for which there ispurportedly ‘hard’ evidence aplenty to bolster such a truth.Some, however, would claim there is little that is actually‘rational’ about economic rationalism (Rees 1995; Norton1997; Quiggin 1997). Theoretically, economic rationalism isonly ‘rational’ in the sense that it operates from a premisethat the individual ‘rationally’ seeks to better the conditionsof his or her own existence, that s/he is not likely to considerit ‘rational’ to compromise those conditions of existence(Rees 1995; Mooney 1999). This is, of course, an ‘instrumen-tal rationality’ where the means justifies the ends. Thispremise of a rational and self-interested being is itself pred-icated on the existence of a humanist individual who is con-sciously self-aware of his or her existence and seeks also to berather more the author of his or her life than anyone elsemight claim to be (Weedon 1987). Indeed, each of the formsof rationality under scrutiny here needs the sort of humanborn of the Enlightenment ideals of individual autonomy,

K Walker


self-defined identity and the will to knowledge (but that’sanother line of thought for another time!).

Economic rationalism has become the fiscal policyorthodoxy of Western and non-Western governmentsworld-wide (Hinkson 1992; Quiggin 1997; Mooney 1999). Inrelation to the Australian context, Quiggin asserts that:

the critical and sceptical thinking that [once] characterised… economic rationalism was gradually replaced by a dog-matic, indeed, quasi-religious, faith in market forces and inthe supreme importance of ‘efficiency’ and ‘competition’.More and more, economic analysis was based on deductionsfrom supposedly self-evident truths, which were [ironically,given the debate before you] effectively immune from anyform of empirical testing (Quiggin 1997, 4).

White and Collyer (1998, 5) agree: ‘The largely uncriticalacceptance of the new doctrine of economic rationalismby powerful members of the bureaucracy and key politicalparties, has relegated social policy to second place behindeconomic policy’, with, I would argue, the effect of elevatingthose forms of inquiry and their outcomes that support sucheconomic policies’ agenda by providing incontrovertibleevidence of what works and what doesn’t at the expense ofany other policy-type that might want to argue otherwise.Economic rationalism to be sure, clearly has something tosay about the relative merits of certain knowledges andpractices, in particular, the knowledges and practices ofscience and EBP (see also Feinstein and Horowitz 1997, 534;Winch, Creedy and Chaboyer 2002, 159).

Thus, the instrumental rationality of economic rationalitycombined with the epistemic rationality of science (empirico-positivism) creates a potent ideological medium to nurturea truth effect of these regimes, the likes of EBP. But thesetogether are still not enough to give it the force it seems tohave acquired in so short a time frame. I am suggesting yetanother rationality interlocks itself with those generated byeconomic rationalism, empiricism and positivism. This is amore accessible, familiar and deeply socially and culturallyembedded rationality born of a particular version of prag-matism; let me explain.

As Gregson, Meal and Avis (2002), working with Rorty’s(1980, 1991) notion of pragmatism, tell us:

Pragmatists accept as true those beliefs and theories thatthey find helpful in making the sum total of their beliefsand experiences intelligible. A pragmatic view of truth isnot concerned with the justificatory procedures that supportcorrespondence, as a means to bridge the gap between indi-vidual beliefs and reality. Instead, as pragmatists we thinkthat the justification for beliefs occurs through obtainingthe greatest degree of coherence in our total stock of beliefsabout what works. Truth is where we can find agreement andconsensus amongst the widest community (27) (emphasisadded).

The community concerning us here is, of course, themedical and healthcare community. It seems to me there is asense in which this community — our community — has cometo believe that there is a great degree of ‘coherence in ourstock of beliefs about what works’ in relation to evidence-based practice. Why else champion the virtues of randomisedcontrol trials, systematic reviews and meta-analyses forproviding the most compelling evidence of effectivenessif not to reinforce and persuade the non-believers, as it were.The scientific community (including the medical subset)has an almost unerring level of ‘agreement and consensus’about the primacy of scientific method as the only methodof choice (despite the caveats from certain quarters as dis-cussed above). But a pragmatism that wants to have it bothways, by claiming it doesn’t need ‘justificatory proceduresthat support correspondence’ between beliefs and reality,and yet at the same moment asserts that if enough peopleendorse something as ‘working’ is good enough, in mymind, is a duplicitous and therefore questionable, position,from which to operate.

It is this notion of a pragmatic as well as an instrumentalor scientific rationality that the proponents of EBP draw on:it would be problematic, if not altogether mad, to suggestthat science and economic rationality were anything but theonly way to conceive of what passes for the truth of clinicalpractice realities, interventions, treatments and so on. Wehave the ‘bottom line’ of the economists, which tells us thatmarket forces and the dollar will ultimately dictate what canand can’t be done by way of interventions/treatment inhealth-care; the pristine and hard truths of science bolstersuch an absolutist version of what works (‘seeing (viathe experiment) is believing’ the empirico-positivistsexhort). History and the triumphs (‘medical miracles’) ofmodern health-care provide ample evidence of this reality. Ina world fraught with ambiguity and flux (Caputo 1987), thecertitudes of these positions are calming and sometimes,empowering.

However, such a pragmatism and the rationality it givesrise to disallows critique because it situates all (worthy)knowledge at the level of ‘commonsense’; commonsense isthat which is supposedly self-evident and is accepted as suchby a particular actor or community. It therefore resists anychallenge put its way because commonsense — as a trait (orotherwise) of human nature — is all but universally regardedas something one must possess; it is definitely a problem ifone is short on or lacking it completely. Pragmatism engen-ders a form of anti-intellectualism that seduces one into asense of false security whereby if enough people agree withyou, then you must be right; why else would so many sub-scribe to EBM (at least rhetorically) when there is as yet little



evidence that it has changed the outcomes for those who arepurported to benefit from it?

A society’s ‘regime of truth’

Thus a multifaceted rationalism constructs a regime of truththat takes the name evidence-based practice and it seemsalmost impossible to challenge its legitimacy in relation toframeworks for guiding clinical health-care policy and prac-tice. However, Traynor (1999, 188) makes a key point inrelation to this issue when he reminds us that:

despite official enthusiasm and considerable investment, theletters and popular comments pages of popular nursingpublications in the UK continue to feature scepticism anda sense that such rationalised approaches to care [as EBP]threaten, or are at odds with, fundamental characteristicsof nursing that are seen as centred around relationships(emphasis added).

Traynor builds on this inherent scepticism from ‘real’nurses (those who actually practice, rather than preach nurs-ing) to discuss an important issue about the way we are allshaped by powerful discursive structures and forces thatwant to have their way with us and make us their name. Therationalising of health-care appeals to a purported need forsystematicity and order in the increasingly complex, sophis-ticated, not to mention risky (Parker 2002; Traynor 2002),healthcare matrix in which practitioners are caught up. Butmuch of what nurses do in providing health-care is boundup in the relationships they create and sustain as they goabout their caring and related activities (see especially, Kit-son 2002); relationships are seldom, if ever, the product ofor responsive to highly rationalised frameworks of percep-tion, let alone, intervention. The sometimes febrile rhetoricof the acolytes of EBP clearly wants nurses to believe that wecan look and be more like the (predominantly white, male)rational healthcare scientist (read medico), if only we thinkand do as he does.

Traynor also points out how nursing practice has beenreluctant and slow to embrace research and the various pos-tures in relation to knowledge and practice they invoke (seealso Roberts 1996, 1998; Bonell 1999; McVeigh et al. 2002).Surely if nursing were desperately in search of legitimationit would long ago have jettisoned its heavy reliance on pro-cedure, ritual, routine and prescription? Wouldn’t it eagerlywelcome evidence-based postures in relation to knowledgegeneration and clinical practice? Of course nursing is yet todevelop a strong research culture in clinical practice; wehave only recently farewelled the apprenticeship model ofeducation in which research and inquiry-based processes ofteaching and learning were all but antithetical (Walker

1997a,b). What import is evidence from research likely to havein a profession yet to be convinced of its supposed veracityand utility? Indeed, the research of Kitson, Harvey andMcCormack (1998) into the implementation of EBP in nurs-ing strongly suggests that it’s not just the nature or qualityand veracity of the evidence that matters whether it is takenup by nurses. It is as much the context in which it is to bedisseminated and the method or how such knowledge is‘facilitated’ into practice by opinion leaders and people ofinfluence, which really matters (and which once again leanson the notion glossed over above that nursing is perhapsmore relatio-centric than the other healthcare professionsand which might not be such a bad thing). Nagy et al. (2001)have argued similarly from Australian data and analysis.

Thus a pragmatism that treats EBP as the way to proceedin the race for more effective and more efficient inter-ventions in health-care — as merely ‘obvious’ because so many(significant) people treat it is as such — is a decidedly worri-some force. It leads to the possibility that where we choose notto follow such a simplistic and uncritical line of thought we aregoing so much against the grain of reasonable (i.e. rational)argument as to be in need of some serious medication.

As an extension of this proposition, the most contentious(and compelling) element in Traynor’s (1999) paper in myview, is that research (and, by extension, EBP) is not a polit-ically neutered, guileless practice but something rathermore sinister than this. As he puts it:

research is a disciplinary practice … [i]t becomes less andless comfortable to not take on, or not to be seen to take on,this orthodoxy. Therefore, it is possible to see research-mindedness not as participation [of our own volition asit were] but as a successful outcome of social control, aneffectively internalised discipline and a new assault upon‘professional autonomy’ by the state (Traynor 1999, 193).

This avowedly critical posture regarding research as adisciplinary technology makes sense in relation to the argu-ment I’ve been advancing here. We are manipulated andseduced by such technologies and the regimes which bothengender and authorise their application. No practice oractor is immune from their effects. All of which is to suggestwe are not the rational authors of our lives as much as wemight like to think (and which is why Foucault (1984) is soinclined to warn us about the ‘dangers’ every potentially newidea harbours). This is not to suggest some paranoid plot isbeing cooked up by our healthcare leaders in relation toEBP and how we ought to embrace its implementation.Rather, it is simply to beg questions about whether it is asappropriate or useful an instrument for progressing ourmultiple agendas for change in these decidedly difficulttimes for nursing.

K Walker


LAST WORDS

In moving the argument to a close, let me further problem-atise this idea of pragmatism as yet another vector of powerin the production of the truth of EBP and BP. Unfortunately,the appeal of a pragmatism such as Rorty’s, is somewhat lop-sided. As radical critical theorists Zavarzadeh and Morton(1994, 151) propose:

In the discourse of bourgeois institutions [for example, hos-pitals, scientific communities, universities, schools] there isno room for non-pragmatic thinking because it questionsthe legitimacy of the actually existing and argues for otherpossibilities. ‘Pragmatism’ pervades all practices ofbourgeois institutions and in a ‘reasonable’ and common-sensical manner institutes a regime of anti-intellectualismthat in effect subjects all knowledge to this test: does itwork? (emphasis added).

Zavarzadeh and Morton (1994) are working with thenotion that such a pragmatism inhibits the development ofalternative ways of conceptualising and then acting in, theworld. The juggernaut of EBP, as I’ve been suggesting, canbe inherently anti-intellectual in the way it all but banishesanything other than empirico-positivist knowledges to themargins of acceptability. This stifles other approaches to theepistemology of healthcare practice and how we shouldprogress its cause by oversimplifying (and thus dispropor-tionately magnifying) its potential to inform our variouspractices (see Naylor 1995; Harari 2001). Our critics suggestthat rather than always being required to ask, as the pragmatistdoes: Does it work?:

[t]he questions should be: Does it work where, and when,and to do what? It might work in the present situation andunder existing circumstances, but such ‘working’ does notin anyway indicate the legitimacy of these practices [suchrandomised controlled trials, systematic reviews and meta-analyses]. (Zavarzadeh and Morton 1994, 151).

Forbes and Griffiths (2002, 144) also resonate with thisidea when they suggest that ‘the majority of effort has goneinto reviews of effectiveness, asking the question “Whatworks?” or “what works best?”’. They propose (in concert withmy earlier argument) that ‘the positivist approach of numer-ical meta-analysis is blind to everything but outcome andtherefore fails to observe the generative mechanisms thatgive rise to such outcomes. It is descriptive rather thanexplanatory’ (146). Forbes and Griffiths suggest instead a‘realist synthesis’ predicated on ‘the axiomatic basis …[that] causal outcomes follow from mechanisms acting incontext’ where ‘the question is not “Does this work?” or“What are the factors?” but “Why or how does this work inthese circumstances?” ’ (2002, 146). Such questions enablewhat I would call a critical realist view (as opposed to the

previously discussed naive realism offered up by empiricio-positivism). This view allows for the possibility that knowl-edge is rather more constructed from than reflected in,anything we might want to call ‘reality’ (and therefore, ismuch more relative than absolute).

We have arrived at a place where I am seriously advocatingthat the enticement by the certainties EBP seems to offer inan increasingly complex and diverse healthcare system andthe multitude of interventions available to healthcare workers,is questionable at best, and may be counterproductive, at worst.My position, in concert with Holmes (2001), is that as nurses,medical practitioners and the like, we ought to be adoptinga posture that is critical of such unreflexive and dogmatictechnologies of knowledge such as EBP (see also Feinsteinand Horowitz (1997, 535)); Winch, Creedy and Chaboyer(2002, 160); Williams and Garner (2002, 12). We ought tonurture an attitude which disallows certainties and theformal definitions to which they give rise because [postmod-ern positions question] both the possibility of certaintybased on ‘foundational’ knowledge [e.g. that derived fromscience] and the kind of rigid systematisations of knowledge[such as EBP] which definitions make possible (Holmes2001, 231).

Indeed, I would go further still, once again drawing onsupport from Holmes (2001, 231), and seriously considerrejecting ‘the expression of knowledge through the kind ofsystematic, flowing theoretical narrative, with consciouslydefined aims and end-points, that characterise disciplines[such as science generally and medical science specifically]’.EBP is but one possible response to the crisis of authorityand legitimation healthcare practitioners find themselvesconfronting in our postmodern times. It is predicated on aninternally consistent ideology that ‘hard’ science (via empir-icism, positivism, economic rationalism and pragmatism) isthe best and only way to further our understandings and thepractices which flow from those understandings. Further-more, the tenacity with which EBP has been able to secureits grip on relatively underdeveloped disciplines such asnursing only provides evidence of how impoverished ourstock of alternative approaches to what constitutes knowl-edge in health-care really is (or ought to be). and while I’maware of recent attempts by the leaders of EBP in nursing tofind ways to develop an equally rigorous and systematicframework for evaluating the merits or otherwise of qualita-tive research (see, for example, Sandelowski, Docherty andEmden 1997; Lemmer, Grellier and Steven 1999; Street2001), I am not convinced that such a framework will helpus in our quest either. Because surely what is at stake here isnot so much a debate about whether ‘hard’ or ‘soft’ knowl-edges are best (for particular ends in particular contexts)



but indeed the whole notion of a regime of truth that caststhe debate in such terms, and then produces specific effectsin relation to our capacity to act in meaningful and produc-tive ways with such knowledges.

The relative bankruptcy of our present position when weconsider how best to proceed in contemporary health-carewith what is now recognised as an explosion and rampantproliferation of available knowledges, techniques, treat-ments and the relative efficiency and efficacy of each, is whyI suggest that EBP has appeared in the times it has. All ofwhich, as I hinted at the outset, is not bad, but rather,dangerous. Dangerous insofar as we lock ourselves into epis-temic frames of reference that allow us only a limited (andlimiting) view of health and health-care. Dangerous in thatthe established hierarchies of knowledge and power (in theform of bureaucratised medicine and an increasinglypoliticised healthcare system) are afforded the opportunityto reign unchallenged with the effect of marginalising andsubordinating other, less authoritative knowledges and exer-cises of power (e.g. nursing’s).

This paper has made a deliberate effort to articulateintellectual work that challenges what I call ‘the order ofthings’ (after Foucault 1972). As Holmes (2002, 77) remindsus, ‘[c]ritical scholarship entails an unwillingness to acceptideas or practice “on authority alone”, to apply traditionalcriteria or methods, or to slavishly follow the status quo andthe intellectual trends it generates’. Nursing has long strug-gled to claim a legitimate voice for itself in the aggressivelyprofessionalising rhetoric of all healthcare practitioners. Wefind ourselves ‘following in medicine’s footsteps’ once againby embracing EBP in the ways that we have. This suggests tome we have much further to travel before we can ever hopeto be recognised, let alone rewarded, for the contributions ourknowledges and the power we exercise as nurses, make tothe well-being of those in our care. EBP has emerged in thetimes that it has because they are times which want to restorea sense of certainty, stability and fixity that was once thoughtto exist. Such a nostalgic, romanticised and sanitised versionof a world can only ever comprise a sort of collective realityfantasy. The world will always constitute a site fraught withcomplexity, ambiguity, contingency and serendipity; the worldhas always been more flux than firmness (Caputo 1987).Before we find ourselves totally at the mercy of EBP, let’s asksome difficult questions about whether it is really best for nurs-ing to be quite so speedy to welcome its supposed benefitsand rewards. After all, the actual effects of EBP in practicerather than in rhetoric and theory, have been little advertisedby even the most enthusiastic of its champions. We couldwell ask, it seems to me: where’s the evidence that evidence-based practice makes the difference it claims to make?

REFERENCES

Asch DA and JC Hershey. 1995. Why some health policiesdon’t make sense at the bedside. Annals of Internal Medi-cine 122(11): 846–50.

Bonell C. 1999. Evidence-based nursing: A stereotyped viewof quantitative and experimental research could workagainst professional autonomy and authority. Journal ofAdvanced Nursing 30(1): 18–23.

Bullock A, O Stallybrass and S Trombley. 1988. The Fontanadictionary of modern thought. London: Fontana Press.

Caputo JD. 1987. Radical hermeneutics: Repetition, deconstruc-tion, and the hermeneutic project. Bloomington and Indian-apolis: Indiana University Press.

Chung MC and P Nolan. 1994. The influence of positivisticthought on nineteenth century asylum nursing. Journalof Advanced Nursing 19: 226–32.

Closs SJ and FM Cheater. 1999. Evidence for nursingpractice: A clarification of the issues. Journal of AdvancedNursing 30(1): 10–7.

Cooke L and P Wollen. 1995. Visual display: Culture beyondappearances. Seattle: Bay Press.

Feinstein AR and RI Horowitz. 1997. Problems in the ‘evi-dence’ of ‘evidence-based medicine’. American Journal ofMedicine 103: 529–35.

Forbes A and P Griffiths. 2002. Methodological strategies forthe identification and synthesis of ‘evidence’ to supportdecision-making in relation to complex health systemsand practices. Nursing Inquiry 9(3): 141–55.

Foucault M. 1972. The archaeology of knowledge, trans. AMSheridan-Smith. London: Tavistock.

Foucault M. 1980. Power/knowledge: Selected interviews andother writings 1972–77, ed. C Gordon. New York:Pantheon.

Foucault M. 1984. The Foucault reader, ed. P Rabinow. NewYork: Pantheon.

French B. 1998. Developing the skills required for evidence-based practice. Nurse Education Today 18: 46–51.

French P. 1999. The development of evidence-based nurs-ing. Journal of Advanced Nursing 29(1): 72–8.

Giroux H and P McLaren. 1994. Between borders: Pedagogy andthe politics of cultural studies. New York: Routledge.

Goode C. 1999. Evidence-based clinical practice. Journal ofNursing Administration 29(6): 15–21.

Gregson PRW, AG Meal and M Avis. 2002. Meta-analysis:The glass eye of evidence-based practice? Nursing Inquiry9(1): 24–30.

Hampton JR. 2002. Evidence-based medicine, opinion-basedmedicine, and real-world medicine. Perspectives in Biologyand Medicine 45(4): 549–68.

K Walker


Harari E. 2001. Whose evidence? Lessons from the phil-osophy of science and the epistemology of medicine. Aus-tralian and New Zealand Journal of Psychiatry 35: 724–30.

Hinkson J. 1992. Misreading the deeper current: The limitsof economic rationality. Arena 98: 112–32.

Holmes C. 2001. Postdisciplinarity in mental health: AnAustralian viewpoint. Nursing Inquiry 8(4): 230–9.

Holmes C. 2002. Academics and practitioners: Nurses asintellectuals. Nursing Inquiry 9(2): 73–83.

Horsefall JM. 1995. Madness in our methods: Nursingresearch, scientific epistemology. Nursing Inquiry 2: 2–9.

Jackson D, J Mannix and J Daly. 2001. Retaining a viableworkforce: A critical challenge for nursing. ContemporaryNurse 11(2–3): 163–72.

Jennings BM and LA Loan. 2001. Misconceptions amongnurses about evidence-based practice. Journal of NursingScholarship 33(2): 121–7.

Juni P, A Witschi, R Bloch and M Egger. 1999. The hazardsof scoring the quality of clinical trials for meta-analysis.Journal of the American Medical Association 282(11):1054–60.

Kim HS. 1993. Identifying alternative linkages among phil-osophy, theory and method in nursing science. Journal ofAdvanced Nursing 18: 793–800.

Kitson A. 1997. Using evidence to demonstrate the value ofnursing. Nursing Standard 11(28): 34–9.

Kitson A. 2002. Recognising relationships: Reflections onevidence-based practice. Nursing Inquiry 9(3): 179–86.

Kitson A, G Harvey and B McCormack. 1998. Enablingthe implementation of evidence-based practice: A con-ceptual framework. Quality in Health Care 7: 149–58.

Lang NM. 1999. Discipline-based approaches to evidence-based practice. A view from nursing. Journal on QualityImprovement. The Joint Commission on Accreditation of Health-care Organisations 25(10): 539–44.

Lather P. 1991. Getting smart: Feminist research and pedagogywith/in the postmodern. London: Routledge.

Lemmer B, R Grellier and J Steven. 1999. Systematic reviewof non-random and qualitative research literature:Exploring and uncovering an evidence base for healthvisiting and decision making. Qualitative Health Research9: 315–28.

Marsh JL, M Westphal and JD Caputo, eds. 1992. Modernityand its discontents. New York: Fordham University Press.

Maynard A. 1997. Evidence-based medicine: An incompletemethod for informing treatment choice. Lancet 349:126–8.

McCormack B, A Kitson, G Harvey, J Rycroft-Malone, ATitchen and K Seers. 2002. Getting the evidence into

practice: The meaning of ‘context’. Journal of AdvancedNursing 38(1): 94–104.

McVeigh C, K Moyle, K Forrester, W Chaboyer, E Pattersonand W St John. 2002. Publication syndicate: In support ofnursing scholarship. Journal of Continuing Education inNursing 33(2): 63–6.

Mooney G. 1999. Health economics and health policy. InEconomics and Australian health policy, eds G Mooney andR Scotton. Sydney: Allen & Unwin.

Nagy S, J Lumby, S McKinley and C Macfarlane. 2001.Nurses’ beliefs about the conditions that hinder orsupport evidence-based nursing. International Journalof Nursing Practice 7: 314–21.

Naish J. 1997. So where’s the evidence?. Nursing Times19(93): 64–6.

Nay R and A Pearson. 2001. Educating nurses to protect thepast or to advance health care?: A polemic. AustralianJournal of Advanced Nursing 18(4): 37–41.

Naylor CD. 1995. Grey zones of clinical practice: Somelimits to evidence-based medicine. Lancet 345: 840–2.

Norton A. 1997. Economic rationalism: Realities in conflict.Quadrant 41(5): 40–3.

Parker J. 2002. Evidence-based nursing: A defence. NursingInquiry 9(3): 139–40.

Pearson A, S Borbasi, M Fitzgerald, I Kowanko and K Walsh.1997. Discussion paper no. 1. Evidence based nursing: Anexamination of the role of nursing within the internationalevidence-based health care practice movement. Deakin, ACT:Royal College of Nursing, Australia.

Petticrew M. 2003. Why systematic reviews reach uncertainconclusions. British Medical Journal 326: 756–8.

Quiggin J. 1997. Economic rationalism. Crossings: The bulletinof the International Australian Studies Association 2(1): 3–12.

Rees S. 1995. Reply to Gow. Australian Journal of Social Issues30(4): 462–4.

Regan J-A. 1998. Will current clinical effectiveness initiativesencourage and facilitate practitioners to use evidence-based practice for the benefit of their clients? Journal ofClinical Nursing 7(3): 244–50.

Roberts K. 1996. A snapshot of Australian nursing scholar-ship 1993–94. Collegian 3(1): 4–10.

Roberts K. 1998. Evidence-based practice: An idea whosetime has come. Collegian 5(3): 24–7.

Rogers WA. 2002. Evidence-based medicine in practice:Limiting or facilitating patient choice? Health Expectations5: 95–103.

Rorty R. 1980. Philosophy and the mirror of nature. Oxford:Blackwell.



Rorty R. 1991. Objectivity, relativism and truth. Cambridge:Cambridge University Press.

Rosen A and M Teesson. 2001. Does case management work?The evidence and the abuse of evidence-based medi-cine. Australian and New Zealand Journal of Psychiatry 35:731–46.

Sackett DL, WS Richardson, W Rosenberg and RB Haynes.1997. Evidence-based medicine: How to practice and teachEBM. New York: Churchill Livingstone.

Salvage J. 1998. Evidence-based practice: A mixture ofmotives? NT Research 3(6): 406–17.

Sandelowski M, S Docherty and C Emden. 1997. Qualitativemetasynthesis: Issues and techniques. Research in Nursingand Health 20: 365–71.

Sarasin FP. 1999. Decision analysis and the implementationof evidence-based medicine. Quality Journal of Medicine92: 669–71.

Schriger DL. 2000. One is the loneliest number: Be scepticalof evidence summaries based on limited literature reviews.Annals of Emergency Medicine 36(5): 517–19.

Seymour W. 1998. Remaking the body: Rehabilitation and change.Sydney: Allen & Unwin.

Stetler CB, M Brunell, KK Giuliano, D Morsi, L Prince andV Newell-Stokes. 1998. Evidence-based practice and therole of nursing leadership. Journal of Nursing Administra-tion 28(7/8): 45–53.

Street A. 2001. How can we argue for evidence in nursing?Contemporary Nurse 11(1): 5–8.

Tonelli MR. 1998. The philosophical limits of evidence-based medicine. Academic Medicine 73(12): 1234–40.

Tonelli MR. 2001. The limits of evidence-based medicine.Respiratory Care 46(12): 1435–41.

Traynor M. 1999. The problem of dissemination: Evidenceand ideology. Nursing Inquiry 6(3): 187–97.

Traynor M. 2002. The oil crisis, risk and evidence-based prac-tice. Nursing Inquiry 9(3): 162–9.

Walker K. 1995a. Nursing, narrativity and research: Towarda poetics and politics of orality. Contemporary Nurse 4(4):156–63.

Walker K. 1995b. Courting competency: Nursing and thepolitics of performance in practice. Nursing Inquiry 2(2):90–9.

Walker K. 1997a. Cutting edges: Deconstructive inquiry andthe mission of the ‘border’ ethnographer. NursingInquiry 4(1): 3–13.

Walker K. 1997b. Dangerous liaisons: Thinking, doing, nurs-ing. Collegian 4(2): 4–14.

Weedon C. 1987. Feminist practice and poststructuralist theory.Oxford: Basil Blackwell.

White K and F Collyer. 1998. Markets and efficiency in thehealth sector. New Doctor. Summer: 5–8.

Williams DDR and J Garner. 2002. The case against ‘theevidence’: A different perspective on evidence-basedmedicine. British Journal of Psychiatry 180: 8–12.

Winch S, D Creedy and W Chaboyer. 2002. Governing nurs-ing conduct: The rise of evidence-based practice. NursingInquiry 9(3): 156–61.

Zavarzadeh M and D Morton. 1994. Theory as resistance:Politics and culture after (post) structuralism. New York: TheGuilford Press.

Documents

Why evidence-based practice now?: a polemic