Empirical Nursing

The Art of Evidence-based Care

Bernie Garrett

• Publisher: Emerald Publishing Limited
• Year: 2018
• ISBN:
  9781787439887
• Topic: Medizin
• Subtopic: Krankenpflege

This book seeks to provide students and practicing nurses with the tools to better understand and engage in scientific arguments to support quality nursing and evidence-based practice. The nature of nursing and its relationship with science remains an area of ongoing debate, controversy and considerable confusion to both students and practitioners. For a science-based health discipline, it is something of a paradox that most nursing students have limited exposure to scientific philosophy education, which is not covered in depth in many modern university nursing programmes. This work seeks to remedy this: in providing material on modern scientific research methods, with particular emphasis on the context of practice, it presents an alternative theoretical iteration of holistic nursing as scientific inquiry. The author is a passionate advocate for empirical and pragmatic approaches to nursing, and the book provides challenging ideas to support a new wave of critical-thinking in contemporary nursing, confronting postmodern dogma with contemporary scientific critique. In doing so, this text engages readers with the art of progressive empirical client-centred care, appropriate for the development of 21st century holistic nursing practice.

Chapter 1

Science and Nursing – Why Should I Care?

Science alone of all the subjects contains within itself the lesson of the danger of belief in the infallibility of the greatest teachers in the preceding generation […] as a matter of fact, I can also define science another way: Science is the belief in the ignorance of experts.

Richard Feynman (1918–1988)

For such a highly science-based discipline, it seems a paradox that nursing education spends so little time actually exploring the philosophy of scientific inquiry. With the current pressures on curriculum space, the same is true for most health professions. Most nurses will not have examined the basis of scientific thought much since high school, and even then, the subject is often not covered in significant depth. Although the methods of scientific inquiry are examined in undergraduate nursing programs, the underlying philosophy (the fundamental nature of knowledge) behind modern science is often only explored in very rudimentary terms, such as by contrasting positivist and humanist approaches. This can give rise to some perplexity over what is and what is not scientific inquiry. This book seeks to address this and give both practicing nurses and students a sound understanding of modern scientific thought and its origins. In this book, the key scientific concepts and principles that underpin contemporary evidence-based health care and the practical application of empirical nursing are explored. Nurses will also find rationales to make sound scientific arguments to support their practice, and to readily detect poorly structured, pseudo-scientific or unscientific arguments and practice.

Readers may ask, ‘Why should I care about scientific philosophy, as I’ve got by fine without any in-depth knowledge of this so far in my career?’ In short, the answer is that in order to provide the best quality professional care, you need to be able to discriminate effectively between alternative therapeutic interventions, quickly identify illegitimate and inaccurate arguments and make decisions that support the optimum healthcare outcomes for your patients and clients. With the explosion of the information age, a growing volume of unscientific, pseudo-scientific, and simply bad science has pervaded nursing and other healthcare disciplines. There has been an erosion of science in nursing education where the philosophy of science and the approaches that underpin evidence-based practice (EBP) often get limited time in the classroom today, or at least get unequal time compared to alternative discourses. The long answer to ‘why should I care?’ is more complex, and in the book, a number of arguments are presented as to why it is important to get a good grounding in this area to be an effective nurse. In particular, this is to counter the increasing use of alternative epistemologies to explain nursing phenomena under the guise of scientific inquiry, and the growing trend in deceptive health practices that are falsely presented as science-based health care. The disciplines of science and nursing are being assailed in both contemporary socio-political structures and within academia. A good knowledge of scientific philosophy will help the reader identify bogus arguments that may impair quality care.

Science Under Siege

Over the last 25 years, an interesting irony has arisen in the way science is perceived versus how much it is relied upon in our increasingly technological world. The public view of science seems to be becoming more and more negative in modern society, despite the fact that that same society has become increasingly more reliant upon it to function. Although we now live in a world that relies on the products of science to fulfil our basic and more advanced needs, post-modern academics now question the fundamental principles of science, and its value to society, and people who put belief in expert opinion or other authorities frequently reject scientific findings in favour of testimonial or dogma (Frazier, 2009; Freese, 2001).

This trend is also becoming apparent in health care and in nursing practice. Naturopaths and media figures such as Jenny McCarthy tell people to ignore the scientific evidence on vaccinations and trust in their vital energy or maternal intuition in making vaccination choices for their children. Spiritually based theories, bizarre alternative therapies, health machines, traditional remedies, and nutritional supplements based on magical explanations proliferate with no substantive evidence of benefits. Many nursing academics would argue that as nurses this is as it should be, as we must consider a multiplicity of narratives and be culturally non-judgmental in such considerations. There is some merit in this as a philosophical stance, but this highlights the alignment of nursing with the methods of the humanities rather than the naturalistic sciences, which few would argue, is now well established. Nevertheless, as health professionals, there is also a duty to balance personal perspectives with evidence, the wider socio-economic implications for health care, and consider the nature of evidence itself (Thorne, 2018).

This polarization of perspectives has been a significant trend in the later part of twentieth-century academia, and particularly in nursing. C. P. Snow suggested, in a famous 1959 Rede lecture (and later in his book), that there were diverging trends between the cultures of science and the humanities which he called ‘the great divide’ and that the split between the two cultures of science and the humanities was a great hindrance in solving the world’s problems (Snow, 1993). John Brockman also suggested there was a third culture of scientists communicating directly with the public about their work in media without the intervening assistance of editors (Brockman, 1995). However, today, incompetent and sensationalist reporting not to mention stereotyping by the media make it difficult for scientists to get their work understood (see Chapter 7 for examples). Advertisers make use of science and scientists to promote products (usually in iconic white lab coats), but science in the media is generally portrayed as nerdy, boring and difficult, whilst scientists are typically portrayed as either morally negligent, mad/evil villains, boffins, eccentric loonies or (perhaps more worryingly) spending their lives developing the latest cosmetic products.

These popular culture images of science and scientists have impacted public trust and confidence in science-based health care. In a 2006 Harris survey of trust in various professions, only about 50% of those surveyed identified doctors and nurses as being completely trusted to give professional advice that was best for patients. In 2010, an Angus Reid Opinion Poll in Canada revealed that an increasing number of Canadians did not trust their doctors (Gillis, Belluz, & Dehaas, 2010). Another 2014 study in the USA confirmed the trend of decreased trust in public institutions and medicine. Whilst in 1966, more than 75% of Americans trusted their physicians, only 58% of people in 2014 agreed that doctors could be trusted (Blendon, Benson, & Hero, 2014). Again, in 2014, during the Ebola crisis of that year, less than one-third of Americans said they trusted public health officials to share complete and accurate information (SteelFisher, Blendon, & Lasala-Blanco, 2015).

Much of the public remains scientifically illiterate due to continuing poor science education in our schools and pseudo-scientific narratives on the web. Even worse, many physicians and nurses fail to truly understand scientific methodology, often failing to discriminate effectively between a sound hypothesis and hyperbole. It is worth considering if nursing is best served by continuing down this path in the future and if scientific literacy is actually necessary for a nursing qualification. Currently, scientific illiteracy is not a major impediment to success in business, politics or in the arts; nursing could soon join their ranks in this respect.

Nursing Epistemology

As professional practitioners focused on health care, nurses are concerned with the why and how questions of health care in their everyday practice. For example, ‘Why is my patient experiencing pain?’ or ‘How is this drug likely to affect my patient’s mental state?’ and so on. In order to answer these in any meaningful way, nurses need some common terms of reference, and a framework of understanding healthcare phenomena. In this, nursing is still struggling as a discipline to establish consensus as to the best way forward, although this is hardly surprising, as philosophers have been struggling with these big questions for centuries. These include such questions as ‘What are the necessary and sufficient conditions of knowledge?’ ‘What are its sources?’ ‘What is the structure of knowledge?’ and ‘What are its limits?’ The study of the nature of knowledge and justified belief is known as epistemology, and this and its relation to nursing knowledge is one of the key areas that seem to interest nursing theorists. The academic journal Nursing Philosophy is primarily dedicated to exploring this very area.

In the consideration of the epistemology of nursing knowledge, it is important to deliberate what is meant by the concept of justification itself. The more recent trend towards evidence-based health care, medicine, and nursing has resolved some of this debate for nursing, but even that has been severely criticized by some nursing academics (Holmes, Murray, Perron, & Rail, 2006). The following chapters explore why an empirical approach makes good sense for developing nursing epistemology and justifying the practice. Science itself represents a belief framework as much as any other, so before proceeding too much further perhaps, it is worth considering what science actually is?

Science and Technology in Nursing

Simply put, science is a way of understanding the world. The term comes from the Latin, scientia, meaning knowledge. Science was originally synonymous with philosophy in the ancient world, and today is still used less formally to describe any systematic field of study. However, here it will be used to describe the system of acquiring knowledge through the use of explanations and predictions that can be tested. The key element of scientific inquiry is that it involves evidence and explanation of the phenomenon by observation and experimentation. In reality, the definition of science itself has come under scrutiny many times, prompting the UK Science Council to publish its latest definition in 2009, which works well here:

Science is the pursuit of knowledge and understanding of the natural and social world following a systematic methodology based on evidence. (UK Science Council, 2018)

Nursing can be considered a scientific discipline in that it represents a collective of academic scholars and practitioners that generate and add to a distinct body of knowledge. It is also an academic discipline in the sense that this knowledge is suitable for both teaching and learning (Phenix, 1962). Nursing is also often described as an applied science (and often resides within such a faculty in universities’ organizational structures) as it is concerned with the application of research into human needs, and it is notable that despite its human focus, it is heavily dependent upon technological innovation for its practice.

Technology can be considered the application of tools and techniques to solve practical problems. It comes from the Greek word technologia meaning art or craft. Although frequently used in relation to science, technology involves the use of technical means derived from both science and art. Technology is often conceptualized in terms of complex electro-mechanical devices but a simple pencil and paper also represents a technology. Ever since humans first began to use tools, technological advancement has progressed. For our purposes, technology may be considered as the application of products from the findings of scientific inquiry, and in this way, nurses are heavily involved in the use of healthcare technologies in their everyday practice, from computers to stethoscopes. So why has health care become so dominated by science and technology?

Science and Medicine in Contemporary Health Care

Few would argue that contemporary health care in the economically developed world remains dominated by medicine. Apart from historical gender-based and socio-cultural rationales, a major reason for this continued dominance is that the discipline has established a track record of effective practice over the last century. To date, this has been unrivalled by alternative health practitioners, and together with the legal control of medication prescription, medicine has maintained dominance in health care. This state of affairs has a relatively short history, however; and before the last century, the success of medical practitioners was not that much better than other health service providers. Even Hippocrates of Kos (460–370 BCE), who is considered the father of medicine and introduced some aspects of science advocating meticulous observation of patients, identified that more than half his patients succumbed to the diseases he was treating them for. In the seventeenth century, there were clear divisions between medicine, surgery and pharmacy, with no clear leader in terms of effective practice. Physicians held university degrees and prescribed a range of remedies, some rather dubious such as medicinal snuffs, effervescent salts and anodyne necklaces. Surgeons were apprenticed, often serving in the dual role of barber-surgeon and practiced bloodletting, whilst apothecaries undertook apprenticeships to make and sell a variety of medications, including traditional remedies with uncertain efficacy. Eventually, with the increasing success of surgery (particularly following the invention of antiseptic surgery by Joseph Lister in 1865), this distinction between medicine and surgery did not survive.

Prior to 1900, there were few effective medical treatments for any of the major illnesses and maladies affecting people of the time. For example, tuberculosis, a major killer, was only identified as a bacillus in 1882, and a successfully immunized against by Bacillus of Calmette and Guérin (BCG) in 1921 in France, 18 years after the first powered aircraft had flown. Even then it was not until after World War II that that BCG received wider acceptance elsewhere in Europe and the Americas and further afield. The use of sound scientific practice by physicians was yet to develop and many doctors were prescribing dangerous treatments in the 1920s, such as chlorine gas for the common cold. There was narcotic analgesia, and insulin, but precious little else in terms of substantial effective therapies prior to 1935, but this was rapidly to change with an exponential increase in effective therapeutic interventions, becoming what has been termed a golden age of medicine (Goldacre, 2008). This golden age was heralded by the advent of a huge range of more effective medical and surgical interventions and health knowledge including antibiotics, anaesthesia, thoracic surgery, vascular surgery, neurosurgery, solid organ transplantation, dialysis, radiotherapy, intensive care, and establishing causative links between diet, exercise, and smoking on cardiovascular and respiratory diseases. These rapid developments in effective proven therapeutic interventions were the product of huge leaps forward in scientific knowledge and technology during this time such as pharmacology, the discovery of DNA, non-invasive medical imaging and information technology. To be balanced, it is also worth recognizing that medicine also made serious blunders causing harm along the way too. For example, Dr Freeman and Watts’ lobotomy procedures in 1936, or Dr Benjamin Spock’s advice to put babies on their front to sleep in 1946. Overall, medicine has become established as a rigorously science-based discipline, requiring qualification in the naturalistic sciences (physics, chemistry and biology) for entry to training, adopting a biomedical framework and developing evidence-based medicine alongside improved ethical codes. This is one of the major reasons that medicine has maintained its status as the preeminent health profession in much of the world.

Nursing Science

Nursing has also benefited from the adoption of a scientific archetype in its professional development, but Nursing now stands at rather a crossroads for its future disciplinary development. Nursing has enjoyed a collegiate and at times tempestuous relationship with our medical colleagues over the last century and a half, establishing professional self-regulation in the face of medical opposition and challenging it when questionable medical practices occurred.

Florence Nightingale (1820–1910) gives a good example of the scientific practice of direct observation and hypothesis with her suggestion to an unheeding British military that most of the wounded soldiers in the Scutari were dying due to poor living conditions, rather than their injuries. She also supported the use of standardized procedural rules for the care of patients, based on the scientific knowledge of the time. Likewise, Mary Seacole, another nursing pioneer of the Crimean war, identified that poor nutrition and unsanitary conditions were a major problem for recovery of soldiers. Nightingale also suggested that ‘Evidence, which we have means to strengthen for or against a proposition, is our proper means for attaining truth’, clearly identifyi...