Gail J. Mitchell

Evidence-Based Practice: Critique and Alternative View:

Recent calls to promote evidence-based practice in nursing raise serious concerns. It has been suggested that evidence should be the primary source of knowledge for nurses. The general literature supporting evidencebased practice indicates that evidence will take nurses away from tradition, intuition, and anecdote to factual, scientific practice. The suggestion is that evidence can provide nurses with directives about how to think and act with patients, families, and groups. However, I contend that the notion of evidencebased practice is not only a barren possibility but also that evidence-based practice obstructs nursing process, human care, and professional accountability. Prior to presenting arguments against evidence as the guide for nursing practice, let me state up front that evidence, defined here as conclusive statements based on findings from randomized controlled trials, has two areas of relevance. First, evidence may provide direction for development of procedures, tech niques, and protocols that nurses and others are asked to per form. Healthcare professionals and nonprofessionals require such knowledge to guide their performance of tasks, and large systems require protocols to coordinate hospital-based care. Naturally, people who require knowledge and skill in these areas value the most effective techniques for preventing com plications or performing tasks such as delivering medication, for instance. But evidence about procedure or service deliv ery is different from knowledge that informs the nurse-person process. Nurses may use techniques and technologies, but the knowledge base of nursing is not technical. Second, evidence may provide one more resource for clients and nurses to consider the latest developments in the di agnosis and treatment of illness and dis ease. This information is available to any person who has access to libraries or to the Internet. Television broadcasts regularly offer the latest developments about links between heart disease and smoking or drug trials and side effects, for example. Healthcare professionals no longer control access to health-related information, and the general public will have increasing opportunities to consider the latest developments and to weigh their relevance in light of personal life circumstances. In a general way, evidence may well be useful to people for making decisions about how they wish to approach their care and what options are available. Pharmacological or medical information may be a launching pad for discussions with peo ple as they figure things out—but evidence will not build a knowledge base for nursing practice. The usefulness of evi dence has been wrongfully cast in the context of legitimizing nursing as a profession instead of describing evidence as one possible resource for supporting clients’ processes of decision-making. Rather than legitimizing nursing, evidence-based practice entraps nurses in the role of medical extender or medical tech nician. But even in these roles, evidence will not provide a foundation for practice. The idea that nurses in practice can access the relevant literature, make the required judgments about credibility of findings, interpret the significance of the findings in light of the guiding theory, and implement changes in practice is inconsistent with current realities. For one thing, nurses are expected to follow procedures written by multidisciplinary groups that are responsible for updating clinical practice in particular medical specialties. In the more technical practice contexts, nurses are rewarded for comply Author’s Note: Please send comments regarding this column or ideas for future Practice Applications columns to Gail J. Mitchell, RN; PhD, Chief Nursing Officer, Sunnybrook Health Science Cen tre, 2075 Bayview Ave., Office-D404, Toronto, Ontario, M4N 3M5 Canada; phone: (416) 480-6100 extension 2778; fax: (416) 4805207; e-mail: gail.mitchell@sunnybrook.on.ca.

Nursing Knowledge and Human Science: Ontological and Epistemological Considerations:

This article examines the meaning of human science in relation to extant nursing knowledge. The origins of the human science tradition are traced to the philosopher Wilhelm Dilthey, who challenged the dominance of the positivist perspective for generating knowledge of the human lifeworld. Specific ontological and epistemological criteria for human science are proposed. Four nursing frameworks, Paterson and Zderads humanistic nursing, Newmans model of health as expanding consciousness, Watsons human science and human care, and Parses theory of human becoming, are found to have consistencies and inconsistencies with the human science tradition. It is proposed that the human science perspective is present in and will continue to be reflected in the evolution of nursing science.

The Role of Theory in Qualitative Research

Increasingly philosophers and scientists have affirmed that all knowledge is theory-laden and that methods are theory-driven. These assertions raise important questions related to the role of theory in qualitative research. There are scholars who propose that qualitative research can enhance understanding and expand theoretical knowledge from a disciplinary perspective. And there are others who contend that qualitative inquiry is purely inductive and that its validity can therefore be judged by the extent to which preconceived theory is absent from it. The purpose of this article is to examine three qualitative methods, grounded theory, ethnography, and phenomenology, and their use in nursing in order to explicate the role of theory in knowledge development. The authors propose that, by nature, inquiry, discovery, and theoretical interpretation coexist simultaneously and must be recognized as such if the theory-research linkage is to advance nursing science through qualitative research.

Neglecting the Importance of the Decision Making and Care Regimes of Personal Support Workers: A Critique of Standardization of Care Planning Through the RAI/MDS

Purpose: The Resident Assessment Instrument–Minimum Data Set (RAI/MDS) is an interdisciplinary standardized process that informs care plan development in nursing homes. This standardized process has failed to consistently result in individualized care planning, which may suggest problems with content and planning integrity. We examined the decision making and care practices of personal support workers (PSWs) in relation to the RAI/MDS standardized process. Design and Methods: This qualitative study utilized focus groups and semi-structured interviews with PSWs (n = 26) and supervisors (n = 9) in two nursing homes in central Canada. Results: PSWs evidenced unique occupational contributions to assessment via proximal familiarity and biographical information as well as to individualizing care by empathetically linking their own bodily experiences and forging bonds of fictive kinship with residents. These contributions were neither captured by RAI/MDS categories nor relayed to the interdisciplinary team. Causal factors for PSW exclusion included computerized records, low status, and poor interprofessional collaboration. Intraprofessional collaboration by PSWs aimed to compensate for exclusion and to individualize care. Implications: Exclusive institutional reliance on the RAI/MDS undermines quality care because it fails to capture residents’ preferences and excludes input by PSWs. Recommendations include incorporating PSW knowledge in care planning and documentation and examining PSWs’ nascent occupational identity and their role as interprofessional brokers in long-term care.

Research-Based Theatre: The Making of I’m Still Here!

This column describes the process undertaken by a team of researchers, artists, and actors to create a research-based drama about living with dementia. Researchers had several studies, guided by the human becoming theory, about what life was like when living with dementia, and an additional study in progress about the lived experience of loss for daughters whose mothers were diagnosed with Alzheimer’s disease. Researchers partnered with an experienced artistic director and playwright in order to craft a script and performance that could help others understand and see life with dementia in a new light. The crafting of the script was also informed by the experiences and insights of actors, healthcare professionals, and persons living with dementia. The play premiered before a group of 100 persons and families living with dementia and has since been performed approximately 40 times to hundreds of professionals and families. The evaluation of the play, at six of the performances, is presented in this column.

Ambiguous Opportunity: Toiling for Truth of Nursing Art and Science

This article questions traditional boundaries between nursing art and nursing science and explores how nurses build knowledge and truth. A brief overview of familiar notions about nursing art is followed by questions that are meant to deepen understanding about nursing and the knowledge required for a discipline. Authors describe understanding as an event that heralds human creation of meaning and potential action. Art is then shown to be a way to enhance understanding and meaningful knowledge when woven with nursing theory to guide practice. Findings from Parse’s research method are described as artistic expressions, and borders that have served to separate notions about nursing art and science are challenged. The hermeneutics of human becoming are presented as beacons for truth and understanding. Authors call for tolerance of ambiguity and openness to support dialogue and discovery.

Patient-Focused Care and Human Becoming Thought: Connecting the Right Stuff

This column is about change, the urgency for change, and the opportunities and struggles involved for those trying to transform the way healthcare services are delivered. Informed consumers and concerned professionals are doggedly pursuing the right stuff to provide a quality of care that is meaningful and satisfying for both providers and the patients and families who enter healthcare systems. For one hospital, Sunnybrook & Women’s College Health Sciences Centre (formerly Sunnybrook Health Sciences Centre), the right stuff began to emerge when principles of patient-focused care were connected with beliefs from the human becoming school of thought (Parse, 1981, 1987, 1998). This novel alliance between patient-focused care and human becoming thought is providing a foundation of understanding that current authors hope will contribute to global efforts to transform healthcare. Patient-Focused Care

Theoretic diversity: evolving paradigmatic issues in research and practice.

Although research and practice differ in that one is the building of knowledge and the other the application of that knowledge, it is suggested herein that there are interesting parallels to explore between the evolving debate on research methods and the emerging theoretic debates on practice. On the basis of the Canadian experience and the trend toward adoption of a single-theory approach, the authors argue for theoretic diversity in nursing practice settings.

Nursing Knowledge and Human Science Revisited: Practical and Political Considerations:

The human science tradition is rooted in human freedom and meaning and oriented toward narrative and dialogical methods. In the past 10 years, human science nursing has grown but the opposition has also increased. Whereas other health disciplines are turning to the study of lived experience, nursing on the whole may be turning away. This article updates progress in human science, including works related to major nursing theories. The authors address practical and political considerations related to language, community, theory-laden knowledge, and tolerance for diversity. The authors conclude that the suppression of human science imperils nursing as a practice of being-with, witnessing, and cocreating quality of life, lived by nurses. But theories live in the actions of those who support them; thus, any place where people seek human care has the potential to support a human science-based nursing practice.

The Experience of Engaging With Research-Based Drama: Evaluation and Explication of Synergy and Transformation:

Researchers describe how audiences experienced a research-based drama called I’m Still Here ; a production about persons and families living with dementia. The research drama was created to help diminish the unnecessary suffering that accompanies the misunderstanding and judgment of persons living with dementia. This article describes the immediate experience of seeing, hearing, and feeling research findings that have been transformed through drama. We explored how participants described the experience of engaging with the drama—what words they used, what was felt, and what lingered after the performance was over. Seven patterns or processes, called patterns of synergy are described: seeing anew; connecting with reverberating truths; placing and relating self; sensing embodied impact, discerning meaningful learning; expanding understanding of perspective; and affirming personal knowing. Each pattern of synergy is considered in light of participant quotes and extant literature. Findings support the promise of the arts in health-related research and education.