Evidence-based nursing. This is the focus of most of the modern nursing discourse (including this blog! Controversy ahead…). In all of nursing’s domains of practice, evidence-base is a hot topic, showing that we are up-to-date, safe, and professional.
There’s just one problem. Being ‘evidence-based’ does not mean nursing is any of these things.
Our profession has doubled down on evidence-based framing in recent years, in alignment with medical professionals. This is nothing new; nursing pioneers have long aligned nursing with aspects of the natural sciences and medical sciences in order to give nursing credibility[i]. I get the sense that nursing’s drive towards evidence is to appear credible alongside medicine, as much as it is to actually improve patient care.
There are several reasons why evidence is not enough to form the basis of nursing knowledge:
- Evidence is not automatically right or good.
One only needs to say “Wakefield” and we know that scientific evidence can be flawed[ii]. While this is an extreme example, there are many published studies that are not rigorous or are clouded by conflicts of interest. Just because something has been studied or published does not make it accurate, safe, or useful.
- The knowledge to practice gap is slow.
Estimates vary, but we know it can be 10-17 years for knowledge to be translated into practice. Even then, it is extremely difficult to change nursing (or medical) practice, and have these changes last. And waiting 2 decades for changes in practice won’t serve our patients in the meantime.
- Standardization is not a good idea.
We know that evidence does not necessarily serve all people or populations. For example, when a study shows that an intubation technique works well in one setting, it does not mean it is safe for all settings. The idea that, if we standardize our care, we will improve patient safety, is fundamentally flawed[iii].
- In many cases, evidence does not exist.
How should nurses practice in the context of Zika virus? We are still learning this. There are patients with Zika who need care in the meantime, and we can’t wait until we have an answer to nurse them.
- Evidence is not ethically neutral.
Evidence is influenced by politics and economics, from start to finish. There are important issues which have not been researched because there isn’t funding available, or other issues are more politically attractive. Even when evidence is available, it can be difficult to fund or adopt; safe staffing ratios are a prime example. Greatest need does not always drive research priorities or implementation.
So what are nurses to do?
I advocate a return to a comprehensive understanding of what makes up nursing knowledge. Carper wrote this paper in 1978[iv], and it’s still relevant and useful today.
Carper outlined that nursing has 4 kinds of knowledge:
If we return to seeing nursing practice as a comprehensive body of knowledge, we can outline nursing work as being multidimensional. Evidence-based nursing has us leaning so heavily on science, that we lose the other factors in our conversations about nursing.
When we are supporting people with mental illness, we know that if we provide community supports, medication, and cognitive-behavioral therapies, we will have better outcomes than if we provide medication alone. This same logic can apply to how we use Carper’s types of knowledge.
We can form the basis of our practice with the art of nursing. We can say, no matter who I meet today, I will promote their dignity, or I will be caring, or whatever works in your practice. When we have a specific problem, such as acute kidney injury, we can use our scientific knowledge and our experience to provide expert care. We can advocate for vulnerable people because this is part of the ethics of nursing. These types of knowledge work together, and give us comprehensive nursing practice.
I think most nurses already integrate different types of knowledge in their practice. What we can change is how we talk about it. We can talk about how we apply different types of knowledge in our work. If we explain nursing knowledge in these domains, it may support nursing students to develop their practice. It may also be easier to talk about challenges, such as ethical dilemmas, when we move away from an overemphasis on evidence.
I believe in the vital role of evidence in nursing practice, as I am a nurse researcher, working to build our professional knowledge base. But I also see that we need more, and we can steer our professional conversation back to the multi-faceted knowledge that really makes up our base.
[i] Wuest, J. (1994). Professionalism and the evolution of nursing as a discipline: A feminist perspective. Journal of Professional Nursing, 10(6), 357-367.
[ii] Godlee, F., Smith, J., & Marcovitch, H. (2011). Wakefield’s article linking MMR vaccine and autism was fraudulent. BMJ, 342, c7452.
[iii] Learn more: http://resiliencecentre.org.uk/fact-sheets/safety-i-and-safety-ii/ Full disclosure- I am a member of the Centre for Applied Resilience in Healthcare.
[iv] Carper, B. A. (1978). Fundamental patterns of knowing in nursing. Advances in nursing science, 1(1), 13-24.