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Commentary Commentary on Evidence, Research, Knowledge: A Call for Conceptual Clarity: Shannon Scott-Findlay & Carolee Pollock Jo Rycroft-Malone, RN, PhD, Cheryl B. Stetler, RN, PhD, FAAN BACKGROUND B ack in 1997 Muir Gray stated, “In the 21st Century, the healthcare decision maker, that is, anyone who makes decisions about groups of patients or populations, will have to practise evidence-based decision making” (p. 1). Now, across the globe there is a general appreciation that decisions made within health care (and other public services) must be based on evidence to a much greater degree than they ever have in the past. In their article, Scott- Findlay and Pollock raise some interesting points about the nature of such evidence. Broadly, the central aim of their article was to urge for a specific (and some would argue) narrower definition of evidence. That is, evidence should be considered to be research. To do this, they set out a mainly semantic argument, but at times, although not explicit, an epistemological one. First, let us set out our epistemological position. Patient- centred nursing is a style of practice that demonstrates re- spect for the patient as a person who values an individual’s way of perceiving and experiencing what is happening to him or her (Titchen 2000). This reflects an influence of ex- istentialist philosophy (e.g., Nietzche, Husserl, Heidegger and Satre) and the humanistic psychology that grew from it (e.g., Carl Rogers). As such, we come from a position that views nursing as a way of working with people to work through and address issues and problems so that the sup- port offered achieves the best possible outcomes for them. Of course, this includes the delivery of care based on the best available research evidence. However, it also means that we are interested in measuring outcomes of patient care as defined by them, rather than (necessarily) limiting these outcomes to those defined by policy or randomised Jo Rycroft-Malone, Senior Research Fellow, Royal College of Nursing Institute. Cheryl B. Stetler, Consultant, Evidence-Based Practice. Address correspondence to Jo Rycroft-Malone, RN, PhD, Senior Research Fellow, Royal College of Nursing Institute, Radcliffe Infirmary, Woodstock Road, Oxford, OX2 6HE; [email protected] Copyright ©2004 Sigma Theta Tau International 1545-102X1/04 controlled trial evidence, for example. As Madjar & Walton (2001) state: Clinical practice ... involves individual people: complex; idiosyn- cratic; living with a host of other concerns; enmeshed in habits and relationships that in one way or another affect their illness and its therapy; and bringing with them personal, family, and cultural val- ues, preferences, motivations, needs, abilities, and expectations. Dealing with individual patients requires scientific evidence and a great deal more (pp. 36–37). In other words, clinical practice requires multiple types and sources of information, or “evidence,” beyond the research-based generalizations of science, as critical as they are. The issues the authors tackle are complex ones to dis- entangle. As they rightly point out, most practitioners may not be concerned with these debates because they would view them as “debates about nothing.” However, they are important considerations for those in the business of try- ing to help others improve patient care and also for those researching the topic. For this reason, it is worth trying to provide some clarity. LACK OF CLARITY Indeed, as the authors state, there is a lack of concep- tual clarity in the literature about the various terms used to define evidence, research, and knowledge, and in an attempt to remedy this there is a consideration of these various terms within the article. Attempts to attain clarity are welcomed; arguably, however, at times this is fraught with difficulties. For example, it is suggested that “evi- dence is a subset of information”—whereas dictionary def- initions would indicate that evidence is indeed information (Collins 1989). In turn, information is knowledge acquired through experience or study (Collins 1989). This would suggest from an etymological perspective, “evidence” could be broader than information from research (study). Similarly, knowledge is described as “the product of knowing and can only reside in a human actor.” However, knowledge can be conceptualised further. Broadly there are 98 Second Quarter 2004 Worldviews on Evidence-Based Nursing

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Page 1: Commentary on Evidence, Research, Knowledge: A Call for Conceptual Clarity: Shannon Scott-Findlay & Carolee Pollock

Commentary

Commentary on Evidence, Research,Knowledge: A Call for Conceptual Clarity:Shannon Scott-Findlay & Carolee Pollock

Jo Rycroft-Malone, RN, PhD, Cheryl B. Stetler, RN, PhD, FAAN

BACKGROUND

Back in 1997 Muir Gray stated, “In the 21st Century,the healthcare decision maker, that is, anyone who

makes decisions about groups of patients or populations,will have to practise evidence-based decision making” (p.1). Now, across the globe there is a general appreciationthat decisions made within health care (and other publicservices) must be based on evidence to a much greaterdegree than they ever have in the past. In their article, Scott-Findlay and Pollock raise some interesting points about thenature of such evidence. Broadly, the central aim of theirarticle was to urge for a specific (and some would argue)narrower definition of evidence. That is, evidence should beconsidered to be research. To do this, they set out a mainlysemantic argument, but at times, although not explicit, anepistemological one.

First, let us set out our epistemological position. Patient-centred nursing is a style of practice that demonstrates re-spect for the patient as a person who values an individual’sway of perceiving and experiencing what is happening tohim or her (Titchen 2000). This reflects an influence of ex-istentialist philosophy (e.g., Nietzche, Husserl, Heideggerand Satre) and the humanistic psychology that grew from it(e.g., Carl Rogers). As such, we come from a position thatviews nursing as a way of working with people to workthrough and address issues and problems so that the sup-port offered achieves the best possible outcomes for them.Of course, this includes the delivery of care based on thebest available research evidence. However, it also meansthat we are interested in measuring outcomes of patientcare as defined by them, rather than (necessarily) limitingthese outcomes to those defined by policy or randomised

Jo Rycroft-Malone, Senior Research Fellow, Royal College of Nursing Institute. CherylB. Stetler, Consultant, Evidence-Based Practice.

Address correspondence to Jo Rycroft-Malone, RN, PhD, Senior Research Fellow,Royal College of Nursing Institute, Radcliffe Infirmary, Woodstock Road, Oxford,OX2 6HE; [email protected]

Copyright ©2004 Sigma Theta Tau International1545-102X1/04

controlled trial evidence, for example. As Madjar & Walton(2001) state:

Clinical practice . . . involves individual people: complex; idiosyn-cratic; living with a host of other concerns; enmeshed in habits andrelationships that in one way or another affect their illness and itstherapy; and bringing with them personal, family, and cultural val-ues, preferences, motivations, needs, abilities, and expectations.Dealing with individual patients requires scientific evidence and agreat deal more (pp. 36–37).

In other words, clinical practice requires multiple typesand sources of information, or “evidence,” beyond theresearch-based generalizations of science, as critical as theyare.

The issues the authors tackle are complex ones to dis-entangle. As they rightly point out, most practitioners maynot be concerned with these debates because they wouldview them as “debates about nothing.” However, they areimportant considerations for those in the business of try-ing to help others improve patient care and also for thoseresearching the topic. For this reason, it is worth trying toprovide some clarity.

LACK OF CLARITY

Indeed, as the authors state, there is a lack of concep-tual clarity in the literature about the various terms usedto define evidence, research, and knowledge, and in anattempt to remedy this there is a consideration of thesevarious terms within the article. Attempts to attain clarityare welcomed; arguably, however, at times this is fraughtwith difficulties. For example, it is suggested that “evi-dence is a subset of information”—whereas dictionary def-initions would indicate that evidence is indeed information(Collins 1989). In turn, information is knowledge acquiredthrough experience or study (Collins 1989). This wouldsuggest from an etymological perspective, “evidence” couldbe broader than information from research (study).

Similarly, knowledge is described as “the product ofknowing and can only reside in a human actor.” However,knowledge can be conceptualised further. Broadly there are

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two distinct categories of knowledge: propositional or cod-ified and nonpropositional or personal (Eraut 1985, 2000;Higgs & Titchen 2000). Propositional knowledge is for-mal and explicit, derived from research and scholarship.Nonpropositional knowledge is derived primarily throughpractice, consisting of professional craft knowledge (thetacit knowledge of professionals) and personal knowledgelinked to the individual’s life experience and cognitive re-sources that a person brings to the situation to enable himor her to think and perform (Eraut 2000; Higgs & Titchen2000). Such a conceptualisation means that evidence canbe derived from multiple sources of knowledge—not justpropositional sources. Therefore, the nature of the evi-dence will be characterised by the source of knowledgefrom which it is derived. As such, research is characterisedby its propositional knowledge roots, clinical and patientexperience by their nonpropositional knowledge roots. Inaddition, it is of interest to note that many hierarchies ofevidence include “consensus” of experts, which accordingto this conceptualisation, relates to both propositional andnonpropositional knowledge.

TANGIBLE

One of the central arguments made by the authors for defin-ing evidence as research, concerns the idea of tangibility(capable of being touched or felt, physical presence; Collins1989). It appears that because research is tangible it willlead to more rational decision making. While research isoften presented in tangible form, that is, in written formin papers, guidelines, and/or reports, as soon as the prac-titioner reads it, it transforms. There is evidence to sug-gest that research is socially and historically constructedby the intended user (e.g., Kennedy 1983; Wood, Ferlie &FitzGerald 1998a, 1998b). What this means in practice isthat if research evidence chimes with our own ideas andreference points about practice, it is more likely to be usedthan research that conflicts or contradicts them. Therefore,the tangibility of research is challenged because it is subjectto a process of transformation from its written form. Morespecifically, in practice this points to a need to translate andparticularise evidence in order to make sense of it in thecontext of the care of the individual patient and environ-ment in which it is to be implemented. On the other hand,this social and personal construction also speaks to the in-fluence of bias and resistance to change among clinicians,that is, to instances where they reject research findings outof hand. This, in turn, speaks to the use by some of localdata as a type of evidence to influence clinician behaviour.For example, quality improvement audits have been usedfor individualized feedback regarding outcomes. Thus, in-formation other than research can be tangible.

Putting aside for the moment the issue of evidence aslocal data, it would be easier or “simpler” to think of evi-dence as research because it is tangible, as that would meanthat it would be easier to observe, study, and measure. Butcan we really be sure that research evidence actually has aphysical presence, particularly when mixed with patients,practitioners, and contexts?

RESEARCH AS DEFINITIVE EVIDENCE

Although not explicit in their philosophical position, itappears that Scott-Findlay and Pollock are coming froman epidemiological perspective, that is, the study of dis-ease in groups of patients and populations (as opposedto individuals)—as evidenced by comments such as, “Weshould begin to admit that what we are seeking to measureand improve in the knowledge utilization field is the useof research findings in policymaking and practice.” Froman epidemiological perspective, a common assumption isthat evidence is research evidence and more specificallyresearch evidence from the quantitative tradition. Morespecifically, evidence from systematic reviews and meta-analyses has taken its place at the top of the hierarchybecause it is less likely to provide “misleading” informa-tion about the effect (both therapeutic and financial) ofan intervention. Research evidence, whether it is quali-tative or quantitative, tends to be perceived as providingwatertight answers to the questions posed. As the authorsstate, evidence is a core concept in law. However, Upshur(2001) points out that in legal terms, it can be used in dif-ferent ways to either refute or corroborate the issue at hand.Thus, an unequivocal understanding of evidence is infre-quent. Upshur (2001) suggests that to conflate research ev-idence with the concept of truth will lead to serious misun-derstandings because the occurrence of definitive studiesis comparatively rare. He suggests that research evidenceneeds to be viewed as provisional, that is, the research ev-idence base for practice is not constant, but evolving.

Additionally, most individual studies have some type oflimitation: even meta-analyses require value judgementsat various steps of the synthesis process; not all researchaddresses details regarding the applicability of findings tospecific subpopulations of patients; and rarely are theseinferential findings absolutely applicable to all patients(Chalmers 2004).

As indicated above, health care has adopted the idea ofevidence as something that is rational, with the potential toprovide proof about the effectiveness of interventions. Weargue that this is rarely the case, particularly when consid-ering the interaction of research evidence with contextual,individual practitioner, and patient variables. Research ev-idence thus provides “working hypotheses” to integrate

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with other sources of evidence of which the clinician isaware to meet individualized patient needs.

RESEARCH AS THE SOURCE OFEVIDENCE

The authors basically argue that research-based knowledgeis the only legitimate form of evidence in health care. Inthe practice setting, however, other sources of data are, inaddition, recognized and utilized by some as transferableknowledge at the local level (Berwick 1996; Stetler et al.1998; Goode & Piedalue 1999). For example, local qualityimprovement data, outcomes data, planning data, etc. playa role in the organization and application of nursing ser-vices. Berwick (1996) also acknowledges that reflection onpractice and sharing of practice knowledge are importantmeans by which to help bring about service improvements.Evidence in these cases can be defined as “information orfacts that are systematically obtained, i.e., obtained in amanner that is replicable, observable, credible, verifiable,or basically supportable” (Stetler, in press). These data donot have the rigor or level of legitimacy as research, but theycan be credible and effectively used to improve patient care.

In addition, patient preferences are at times explicitlylisted as a type of this internal evidence. This implies thatthe collection of patient preference data should also bereplicable, credible, etc., so that such information is ap-propriately and accurately integrated into the plan of care.Without such rigor or skill on the part of the clinician, apatient’s lack of knowledge or fear (e.g., avoidance of painmedication) may influence the plan of care, rather thanthe patient’s basic values. So too with clinical experience.Designation of this as evidence implies that it does notinclude individual, unsystematic views, or isolated opin-ions. For evidence-based practice, such information shouldcome from affirmed experience. Affirmed means that ex-periential observations or information has been reflectedupon, externalised, or exposed to explorations of truth andverification from various sources, for example, colleagues(Upshur 1997; Stetler et al. 1998; Davies, Nutley & Smith2000; Rycroft-Malone et al., in press; Stetler, in press).

RESEARCH AS AN INFLUENCEON DECISION MAKING

We applaud any attempt at providing clarification to theterms we use in our evidence-based practice endeavours.However, perhaps the clarity is this—practitioners are mak-ing decisions on a second-by-second, minute-by-minutebasis. A number of pieces of information influence thesedecisions, including clinical experience, patient experienceand preferences, local data, and research evidence.

The greatest challenge, as the authors suggest, still liesin determining how these influences are weighted, and wewould also add, how these influences are blended and towhat extent they positively impact patient outcomes.

NOTE TO READERS

If you would like to comment on any of the issues raisedin the article or commentary, please e-mail the editor:[email protected].

ReferencesBerwick D.M. (1996). Harvesting knowledge from im-

provement (editorial). Journal of the American MedicalAssociation, 275(11), 877–878.

Chalmers I. (2004). Well informed uncertainties about theeffects of treatments. British Medical Journal, 328(7438),475–476.

Collins Concise English Dictionary (1989).Davies H.T.O., Nutley S. & Smith P. (2000). Intro-

ducing evidence-based policy and practice in publicservices. In H.T.O. Davies, S. Nutley & P.C. Smith(Eds.), What works? Evidence based policy and prac-tice in public services (pp. 1–11). Bristol: The PolicyPress.

Eraut M. (1985). Knowledge creation and knowledge use inprofessional contexts. Studies in Higher Education, 10(2),117–133.

Eraut M. (2000). Non-formal learning and tacit knowledgein professional work. British Journal of Educational Psy-chology, 70(Pt 1), 113–136.

Goode C. & Piedalue F. (1999). Evidence-based clinicalpractice. Journal of Nursing Administration, 29(6), 15–21.

Higgs J. & Titchen A. (2000). Knowledge and reasoning. InJ. Higgs & M. Jones (Eds.), Clinical reasoning in the healthprofessions, 2nd Ed. (pp. 23–32). Oxford: ButterworthHeineman.

Kennedy M. (1983). Working knowledge. Knowledge Cre-ation Diffusion & Utilisation, 5, 193–221.

Madjar I. & Walton J.A. (2001). What is problematic aboutevidence? InJ.M. Morse, J.M. Swanson, & A.J. Kuzel(Eds.), The nature of qualitative evidence (pp. 28–45).Thousand Oaks: Sage.

Muir Gray J.A. (1997). Evidence-based healthcare. How tomake health policy and management decisions. London:Churchill Livingstone.

Rycroft-Malone J., Seers K., Titchen A., Kitson A., HarveyG. & McCormack B. (in press). What counts as evi-dence in evidence-based practice? Journal of AdvancedNursing.

Stetler C. (in press). Stetler model of research utilization

100 Second Quarter 2004 �Worldviews on Evidence-Based Nursing

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& evidence-based practice. In B. Melynk & E. Fineout-Overholt (Eds.), Evidence-based practice in nursing andhealthcare: A guide for translating research evidenceinto best practice. Philadelphia: Lippincott Williams &Wilkins.

Stetler C., Brunell M., Giuliano K., Morsi D., Prince L. &Newell-Stokes V. (1998). Evidence-based practice andthe role of nursing leadership. Journal of Nursing Admin-istration, 28(7/8), 45–53.

Titchen A. (2000). Professional craft knowledge in patient-centred nursing and the facilitation of its development. Uni-versity of Oxford doctoral thesis. Kidlington: AshdalePress.

Upshur R.E.G. (1997). Certainty, probability and abduc-

tion: Why we should look to C.S. Peirce rather thanGodel for a theory of clinical reasoning. Journal of Eval-uation in Clinical Practice, 3(3), 201–206.

Upshur R.E.G. (2001). The status of qualitative researchas evidence. In J.M. Morse, J.M. Swanson & A.J. Kuzel(Eds.), The nature of qualitative evidence (pp. 5–26).Thousand Oaks, CA: Sage.

Wood M., Ferlie E. & FitzGerald L. (1998a). Achievingchange in clinical practice: Scientific, organisational andbehavioural processes. Coventry, UK: University of War-wick, CCSC.

Wood M., Ferlie E. & FitzGerald L. (1998b). Achievingclinical behavioural change: A case of becoming inde-terminate. Social Science and Medicine, 47, 1729–1738.

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