Deconstructing Evidence-Based Practice

Dawn Freshwater, Gary Rolfe

• Publisher: Routledge
• Year: 2004
• eBook ISBN: 9781134305445
• Topic: Medicine
• Subtopic: Caregiving

This innovative book strips the concept of evidence-based practice back to basics using deconstructive analysis, so that readers can move towards a clearer understanding of it. The practitioner is guided through a number of case studies in which the authors examine how the concept of evidence-based practice has been used in a variety of clinical settings. Divided into three parts, the book provides a deconstruction of key texts related to evidence based practice, weaving together contemporary themes in healthcare research.

Deconstructing Evidence Based Practice is essential reading for nurses and other health practitioners who need to understand more about evidence-based practice and who want to learn methods of critical thinking that will be invaluable in judiciously informing their practice.

Preface

‘Here is what I wrote, then read, and what I am writing that you are going to read. After which you will again be able to take possession of this preface which in sum you have not yet begun to read, even though, once having read it, you will already have anticipated everything that follows and thus you might just as well dispense with reading the rest.’
(Jacques Derrida - Outwork, prefacing)

Preface 1

The authority of the ‘is’

… perhaps deconstruction would consist, if at least it did consist, in… deconstructing, dislocating, displacing, disarticulating, disjointing, putting “out of joint” the authority of the “is”.¹

cont. from p.213l it pretends to’². All endings, all beginnings, are arbitrary; no, artificial. Let's pretend to begin then.

Before the text

Our explicit intention here has been to write an academic book. That is not to say, a book that is divorced from practice; on the contrary, we have tried to write a book that will encourage you to think deeply about practice and perhaps to change the way you practice as a result of those thoughts. We appreciate that, to a certain extent, our intention flies in the face of some current trends, particularly the trend for books and journals that claim to help the ‘busy practitioner’ to practice more effectively without having to take the time to do too much reading or thinking.

We do, of course, recognise that many practitioners are extremely busy people who are perhaps so immersed in their day-to-day practice that they have little time to think, let alone to read. However, we also believe that to practice is not merely a case of doing, even if it is ‘evidence-based doing’. We believe that practice entails reading about doing, thinking about doing, writing about doing, reading about thinking about doing, writing about reading about thinking about doing, and indeed, most other permutations on the above. And until healthcare workers and their managers recognise, accept and facilitate this expanded concept of practice, they will find it difficult to make the leap from workers to practitioners and from a job to a profession.

We believe that any concept of practice must include a reflexive critique of that practice. But herein lies the dilemma, since any practice that looks inwards at itself will only ever be able to judge itself according to its own preestablished criteria. All professions, all disciplines, all discourses include an essence, a set of ‘givens’ that are seen as being so fundamental that they do not need to be questioned; propositions and beliefs that, as the American constitution says, ‘we take to be self-evidently true’. For example, the aim of nursing is to care for the sick, the aim of medicine is to preserve life, the aim of research is to generate knowledge, good practice is based on best evidence, and so on. These self-evident first principles are rarely challenged, and represent what the French philosopher Jacques Derrida referred to as ‘the authority of the “is”’³.

Our aim in writing this book is to challenge the authority of the ‘is’, to initiate a critique of health and social care practice and theory that does not emanate from (and is therefore not bound by the rules of) the practice and theory that it seeks to criticize. For example, we believe that it is important to be able to explore issues of validity and reliability in research without accepting as self-evident that research is concerned with the pursuit of knowledge and/or truth. We want to be able to explore ideas of caring in nursing without accepting as self-evident that caring is a necessary component of nursing. We want to be able to explore the aims of healthcare without accepting as self-evident that health is necessarily a desirable aim in itself. But we also wish to apply this criterion to the very act of criticism itself. We want to explore an approach to critique that is not bound up with the usual rules and expectations of academic scholarship. We believe that what Derrida referred to as ‘deconstruction’ offers just such an opportunity to step outside of these preconceptions. In an age where evidence-based practice is fast becoming the gold standard in all areas of health and social care, deconstruction highlights the importance of challenging the underlying contradictions that are inherent in all texts that contain the evidence which guides our practice. But it goes further: it not only challenges the accepted view of evidence-based practice as the gold standard, it also challenges the very idea of a gold standard, of a preferred or authorised way of doing things.

Into the text

In the introduction to his influential book on the theory and practice of deconstruction, Christopher Norris writes that ‘Deconstruction is the active antithesis of everything that criticism ought to be if one accepts its traditional values and concepts’⁴. Foremost in the list of traditional values and concepts is the idea that a text is a representation of a single and (as far as possible) unambiguous meaning, and that the meaning placed in the text by its author can be uncovered, elucidated and challenged by the critic. Deconstruction, then, is the active antithesis of this concept. It seeks not only intellectually to undermine the idea of a single fixed meaning that can be teased out and explored, but also actively to demonstrate the absurdity of that idea by revealing the hidden contradictions and aporias⁵ inherent in all texts, along with the ways in which authors consciously or unconsciously attempt to conceal those contradictions beneath a seemingly logical and rational facade. Much of the activity of deconstruction therefore takes place in the ‘margins of the text’, in the seemingly innocuous and even superfluous passages where the author's guard is down. As Norris tells us, ‘To “deconstruct” a piece of writing is therefore to operate a kind of strategic reversal, seizing on precisely those unregarded details (casual metaphors, footnotes, incidental turns of argument) which are always and necessarily, passed over by interpreters of a more orthodox persuasion’⁶.

Deconstruction is a response not only to the idea of an authoritarian text (that is, a text that upholds the authority of the ‘is’, a text which claims to ‘tell it like it is’), but also to the idea of an authoritative approach to critiquing that text, and in particular, to the doctrine of structuralism, which seeks to provide a more or less scientific method for what was previously regarded as the art of criticism. The structuralists, as upholders of the traditional values of criticism, advocate a single method in order to uncover a single meaning in the text. In contrast, deconstruction shuns the idea of a single method. As Roland Barthes, a structuralist-turned-post-structuralist, observed: ‘At a certain moment, therefore, it is necessary to turn against Method, or at least to treat it without any founding privilege as one of the voices of plurality’⁷. Norris goes even further to suggest that deconstruction does not seek to replace Method with multiple methods, but rather to reject the very notion. Deconstruction is therefore less a method and more a perspective. It involves a certain way of thinking about texts and about itself (what might be called an interpretive self-consciousness) that troubles the underpinning assumptions of the text. It challenges the notion of wholeness within texts, arguing that all representation is partial. The internal fissures of the text are revealed not only through what is written; fault lines are also detected within the silences, the gaps, the margins, the aporias and between the lines.

We can see, then, that To present “deconstruction” as if it were a method, a system or a settled body of ideas would be to falsify its nature and lay oneself open to charges of reductive misunderstanding’⁸. This clearly offers a challenge to the would-be deconstructionist: if there is no method, then what exactly is deconstruction and how is it to be learnt and practised? We might turn to Jaques Derrida, the ‘founder’ of deconstruction, for an answer. However, he tells us merely that ‘deconstruction loses nothing from admitting that it is impossible’⁹. In fact the act of deconstruction is, in one sense, unnecessary, since a ‘deconstructive reading attends to the deconstructive processes always occurring in the texts and already there waiting to be read’¹⁰. The deconstructive process comes not from the reader/critic but from the text itself; it is already there, it is the tension ‘between what [the text] manifestly means to say and what it is nonetheless constrained to mean’¹¹. To say that deconstruction is impossible is therefore to acknowledge ‘the impossible desire of language … to make present the permanently elusive’¹².

There is no method to deconstruction because texts literally deconstruct themselves in their impossible attempt to employ language as a ‘transcendental signifier’¹³, that is, as a way of ‘pointing’ at some eternal truth or other. As Spivak observes, ‘All texts … are rehearsing their grammatological structure, self-deconstructing as they constitute themselves’¹⁴. All that the budding deconstructionist needs to do, then, is write, since in the final analysis, deconstruction is writing. Furthermore, it is writing with no preconceived goal; as Roland Barthes put it, ‘to write is an intransitive verb’¹⁵, a verb without an object, an end in itself. Deconstruction manifests itself in the process of writing rather than in the product: ‘Deconstruction takes place, it is an event that does not await the deliberation, consciousness, or organization of a subject’¹⁶.

But if this is indeed the case, then deconstruction is impossible in another and more tangible sense. Firstly, of course, the process of deconstructive writing produces a second text as a supplement to that which it seeks to deconstruct, which is itself (in Spivak's words) self-deconstructing as it constitutes itself (what we might call the process of being re-invented whilst simultaneously being invented). Secondly, as we have seen, there is no single authoritative and ‘correct’ deconstructive reading/writing of any particular text. Therefore, each text contains within itself the possibility of a vast number of supplementary deconstructive texts, and each of those is likewise open to further deconstruction ad infinitum in an infinite regress. As Spivak points out, ‘The fall into the abyss of deconstruction inspires us with as much pleasure as fear. We are intoxicated with the prospect of never hitting bottom’¹⁷. But we do not even need to write in order to fall into the abyss. The very act of reading creates a new and different text; that is to say, reading writes. To deconstruct a text is therefore to embark on an endless (and thus, in a sense, an impossible) journey, in which the destination is constantly revised as soon as it is realised. It is a leap in the dark in the knowledge that you might never again set foot on solid ground, indeed, you might even begin to question if there ever was solid ground.

We can see, then, that although deconstruction is first and foremost a way of writing, it is a particular kind of writing that transgresses many of the accepted rules of ‘good’ academic scholarship. Unlike most academic writing, deconstruction is not concerned with the clear communication of a single authoritative message. In fact, it seeks to undermine the very notion of the possibility of clear communication, since ‘meaning and language undermine each other … for language is not the vehicle of meaning but its destroyer’¹⁸. As Derrida asks:

Is it certain that there corres...

Table of contents

• Front Cover
• Half Title
• About the Author
• Title Page
• Copyright
• Contents
• Dedication
• Preface 1 The authority of the ‘is’
• Preface 2 The first time I saw Jacques Derrida
• Preface 3 The event of a narrative
• Deconstruction 1 Listen/read/write: an exercise in deconstruction
• Deconstruction 2 That dangerous supplement...
• Deconstruction 3 Analyse this
• Afterword 1 Rules for reading
• Afterword 2 Writing in the margins
• Afterword 3 A tissue of truths
• Index