In the previous section, Estabrooks raised the question of the ability of the EBP framework to provide the "best evidence" in nursing practice and the danger of excluding nurses in decision-making tasks as a result of EBP prevalence and dominance.
Rolfe, while he analyzed the empirical foundations of EBP, also looked at it from a practical perspective, or how EBP is applied in the current practice of nursing. Identifying the problem of EBP as the question of its "technical rationality," Rolfe uncovered an important issue that best describes also Estabrooks' contentions in her article: the "theory-practice" gap in nursing practice.
In thoroughly discussing this phenomenon in nursing, Rolfe illustrated how theory-practice gap occurs in the practice scenario (39):
First, that nurses rarely read research reports; second, that when they do read them, they rarely understand them; and third, even when they do read and understand research reports, they are reluctant or unable to apply the findings to practice for a number of personal and structural reasons.
This illustration of the real-life setting aptly describes why Rolfe, as well as Estabrooks, questioned the ability of EBP to provide the "best evidence" that nurses can use in their practice. Evidently, from this phenomenon in nursing, nurses do not find relevance to the information that they encounter or receive from EBP-based researches.
It is at the occurrence of this scenario, then, that the author posited that the problem with EBP is its tendency to become too theoretical to the point that it is no longer communicated well and effectively to its audience, the nurses: "...perhaps the problem is one of inappropriate findings resulting from inappropriate research methodologies" (39). This is the question of technical rationality that Rolfe introduced in the article, wherein he pondered over the ability of EBP research methodologies to provide the "best evidence" that nurses can use or apply in their practice. Through the technical rationality question, the author was able to address Estabrooks' critical questioning of whether RCTs and other EBP-based research methodologies yield the "best evidence" and are proven to be suitable to nursing practice or not.
Apart from the question of technical rationality, another important factor that questions the ability of EBP in providing the "best evidence" in nursing practice, and another scenario that supports the existence of theory-gap practice in nursing, is the characterized "one-way flow of information from research and researchers, through academic journals and textbooks, to nursing practice and practitioners" (39). This process demonstrated the process in which nurses become "excluded" from their own practice, as Estabrooks earlier agued. For Rolfe, this one-way flow of information subject nurses to researchers and information, wherein "nurses are directed in their everyday practice by the writing of theorists."
In an attempt to create a solution and fill in the theory-practice gap, the author provided recommendations on the type and method of researches that can prove to be most effective and suitable to nursing practice. Rolfe's proposal included an attempt to practice nursing "as a science rather than a technical science," which should take into consideration that nursing, as a field of medical science, relies mostly on patient cases rather than the population in general. This is an important consideration in nursing practice because each case or patient is treated individually, and each case is considered unique and different from each other. More efficient conduct of research, in order to be suitable to nursing practice, then, are researches that "conduct single-case research" and "reflection in action" or "experimenting in action" approach (40).
These recommendations already delved into the concept of reflective practice, which was only elucidated in Rolfe's discussion, and implied only from Estabrooks' analysis. In supporting the reflective practice to nursing, Rolfe reiterated that research as applied to nursing practice is complex, since there are important factors to be considered, such as patients being case-specific and bounded by cultural differences. Moreover, social science research, from which EBP is based, discusses people in general, while nursing focuses on individual cases. Thus, reflective practice is appropriate for nurses as a research framework because it eliminates the problem of utilizing methods that tend to generalize, rather than probe deeply, into a specific nursing issue or phenomenon. Rolfe's discussion of the theory-practice gap highlighted the fact that not all research can be applied to nursing practice, especially if these researches attempt to generalize a particular group or population, since what is needed is empirical evidence for individuals.
The author's ultimate recommendation of creating a 'balance between scientific method and nursing inquiry' best describes the stance of reflective practice in nursing. In the section that follows, reflective practice, although not termed as such by Avis (2006), but described empirically and termed as "critical reflection," becomes the central discussion as applied to nursing practice.
Critical reflection/Reflective practice and its Empirical Foundations
One of the primary concerns of Avis (2006) when he discussed EBP is to provide an efficient way to utilize research without nurses having to resort to "intuition" as the primary basis of their decision-making and practice. In effect, the author wanted to create a balance, as Rolfe explicated, between scientific methods and nursing inquiry. Avis achieved this objective by discussing in detail how critical reflection, or reflective practice, is developed and is considered the most efficient way of balancing research without disregarding nurses' experience in their practice.
In setting the ground for reflective practice as a new framework in nursing practice, Avis discussed hypothesis-making and critical reflection as separate elements first. After discussing these components, they are fused together to create the reflective practice framework, which is a more complex but appropriate framework of putting nurses' experiences into the theoretical foundations and technical aspects of EBP-based research.
Avis's main argument in the article is that "knowing how to practice [sic] is a matter of expertise," and he further elaborated on this point by stating that nursing knowledge and practice should be based on expertise, which is composed of intuition and rational decision-making. Achieving a balance between a nurse's intuition and rational decision-making is similar with Rolfe's initial assertion that EBP, or at least a nursing framework, should achieve an equilibrium between scientific method and nursing inquiry.
Rational decision-making is represented in the article by hypothesis-making, which embodies most EBP researches that are quantitative in their design and methods. For the author, hypothesis-making, as well as the science of positivism from which rationalism originated, are culture-bound in that what information human society decides to believe are actually decided upon subjectively, despite the objective generation of the said information. In his elucidation of the science of positivism, Avis countered that even though positivism is 'knowledge based on observation' of the external environment, it is still subjective as a science because what people choose to believe in what they observe and experience becomes the basis of their knowledge. He stated that 'not all variables can be observed,' and what people choose to observe is the subjective part of positivism, while the observation of the external environment or of an experience is the objective aspect of observation / positivism.
Hence, it is not surprising, then, that hypothesis-making and -testing are also based on one's belief on a particular phenomenon or issue. In arguing this point, Avis asserted that, we propose hypotheses concerning the subject matter that is being studied and test them for consistency with our other beliefs, assumptions, and interpretation in order to form a comprehensive system of belief that is logically coherent.
Further, Avis explicated on how extant knowledge and dominant and prevalent beliefs and ideologies survive within human society. He declared that human knowledge is what society collectively believes to be the truth, which is synonymous with hypothesis-testing, wherein the investigator or researcher tests the truth or falsity of his/her belief on an issue or phenomenon. Hypotheses are media through which an individual can project his/her beliefs, and support these beliefs with empirical evidence. The author profoundly explained the role that hypotheses plays in humanity's attempt to seek the truth about their world: "a hypothesis is like a chemical reagent that causes other substances to appear, use of a hypothesis allows specific features of experience to become apparent."
In effect, hypothesis-making is the process by which the individual projects his/her beliefs to be supported by empirical data, and hypothesis-testing is the process of transforming these beliefs into "truths," or what the individual beliefs to be a fact based on what he observed/tested from his experience of the external environment. Ultimately, what Avis points out in the article is that the objective perspective cannot be separated from the subjective perspective; both perspectives function together to create a 'knowledge base' that humans can utilize and collectively agree upon as 'universal truths,' for a particular period or time in history.
Given that hypotheses and quantitative forms of research are actually based…