Reflective Practice and Evidence-Based Practice in Nursing

Introduction

Nursing, as both a profession and a vocation within medical science, is considered professionally and emotionally gratifying. The nurse, as a medical practitioner, is able to provide invaluable service not only to the profession itself but, most importantly, to patients and to society at large. The social relevance of nurses in the fields of medical science and social services makes them indispensable members of society.

It is crucial, therefore, that a thorough examination of nursing as a practice be conducted in order to assess the efficiency of nursing, based on both its theoretical foundations and its applications. Among the perspectives currently dominant in the nursing profession is the utilization of evidence-based practice (EBP), defined as the "conscientious, explicit, and judicious use of current best evidence in making decisions about the care of individual patients" (Estabrooks, 1998, p. 21).

EBP, as one of the dominant perspectives in nursing research and practice, is critically analyzed by nurses who have contemplated its implications when applied to both nursing research and clinical practice. In the sections that follow, these critical discourses on EBP in the nursing profession are discussed based on how each author addressed a particular aspect of EBP — whether the empirical or practical merits and disadvantages of the framework, or both.

Evidence-Based Practice in Nursing: An Overview of Critical Perspectives

The discussion and analyses of the articles in this paper assume the position that reflective practice should be the central perspective governing nursing research and practice — a perspective that fuses and takes into consideration both scientific inquiry and nursing experience. By adopting this perspective, nurses, researchers, and practitioners alike can avoid the dilemma posed by the nursing community's limited receptivity to EBP and the ongoing conduct of research that cannot be efficiently translated and applied to nursing practice.

The articles included in this discussion all address EBP in nursing; however, each author centers on specific aspects of EBP, which may be empirical, practical, or political in nature. Carole Estabrooks' (1998) inquiry into EBP as the current dominant perspective in nursing research questioned its applicability to nursing practice, providing both political and empirical evidence of why EBP may not be a reliable framework upon which nursing knowledge and practice should be based.

Following Estabrooks' analysis is Rolfe's (2006) concise but thought-provoking examination of what he termed the "theory-practice gap" of EBP in nursing. Rolfe centered his discussion on the empirical and practical implications of this dilemma, later recommending measures through which nurses, as researchers, could develop a new nursing framework combining both inquiry and practice. Empirically supporting Rolfe's findings is Avis's (2006) discussion of EBP, which is centered on establishing evidence that EBP is devoid of the reflective quality needed in nursing as a profession and vocation. Finally, McCormack (2006) primarily addressed the political issues surrounding the implementation of EBP in nursing, positing that the nursing community's limited receptivity to EBP stems from its being too theoretical and insufficiently "action research"-oriented.

Experience vs. Information: Estabrooks on the Politics and Empirical Foundations of EBP

Carole Estabrooks centered on both the political and empirical implications of EBP — specifically evidence-based decision-making — in nursing practice. She assumed the stance that the nursing community, researchers and practitioners alike, still has much to learn about EBP as a relatively new framework, and that its recent inception in nursing practice makes it a subject of critical scrutiny, especially regarding its empirical merits. In questioning the efficacy of EBP as the dominant nursing framework, Estabrooks argued that it is not a suitable framework because it is too theory-based and lacks applicability in practice.

Estabrooks' reason for questioning EBP is rooted in nursing's growing dependency on research protocols as the primary basis for practice. She believed that EBP is not suitable for nursing, a discipline that depends mainly on experience as the basis of knowledge, not merely on research information. Having established this, she posed the key question: whether "research, when used by clinicians, results in improved client/patient outcomes" (p. 19). This question, if answered affirmatively, would establish the efficacy of EBP in bringing research information to nursing practice. However, Estabrooks argued specific points demonstrating the limited applicability of EBP research to nursing practice.

In a survey of 600 staff nurses, Estabrooks sought to determine whether research information is indeed a meaningful source of knowledge among nurses. Most notably, she sought to identify nurses' own conceptions of knowledge. It was found that "experience" emerged as their primary source of knowledge, followed by "nursing school," "workplace," "physicians," "intuition," and "what has worked for years" (p. 23). Research information did not figure as a relevant or significant factor in determining nurses' knowledge of their practice.

Interestingly, when the same nurses were asked to identify their sources of information regarding their practice, they cited research journals — specifically nursing journals — as their major source (p. 26). This discrepancy demonstrates that nurses may use nursing journals to gain nursing information, but ultimately, when faced with decision-making tasks, they resort to experience. These survey results established that, in the case of the nurses studied, research does not readily translate into application and implementation in nursing practice.

Estabrooks also examined how quantitative methods are applied — and have repeatedly failed to prove their applicability — to nursing practice. She cited physicians' and nurses' regard for the randomized controlled trial (RCT) as an example. The RCT is an experimental method prevalently used in nursing research and considered the "'gold standard' of evidence" (p. 27). Estabrooks expressed doubt over this quantitative method, questioning whether data generated from such studies actually provide "best evidence" in nursing practice. Although she did not resolve this question within the article, she implied that over-reliance on EBP research has obscured the question of whether such research is suitable — or even applied — to nursing practice at all.

Estabrooks also examined the political implications of implementing EBP in nursing. She observed that the establishment of EBP as a dominant framework would mean a centralization not only of the power to select which nursing information to use, but also of the power to determine what nursing practices are implemented in healthcare facilities. Since EBP is governed primarily by physicians and researchers, Estabrooks feared that its continued dominance could result in the exclusion of nurses from decision-making and policy issues. While she was "not rejecting the idea of evidence-based practice," she hoped it would not be used as "a tool to disempower clinicians or to cause more blaming of clinicians for not doing it" (p. 18).

Similar to Estabrooks' thrust, Gary Rolfe's (2006) analysis of EBP in nursing specifically addressed how efficiently research information is translated into practice. Where Estabrooks raised the question of whether EBP can provide "best evidence" and warned of nurses being excluded from decision-making, Rolfe examined the problem from both an empirical and a practical perspective.

The Theory-Practice Gap: Rolfe on Research and Its Application

Identifying the central problem of EBP as a question of "technical rationality," Rolfe uncovered an issue that aptly describes Estabrooks' contentions as well: the "theory-practice gap." He illustrated how this gap manifests in practice (p. 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 real-life clinical settings explains why both Rolfe and Estabrooks questioned EBP's ability to provide the "best evidence" for nursing practice. Nurses evidently do not find the information contained in EBP-based research sufficiently relevant to their work. Rolfe argued that "perhaps the problem is one of inappropriate findings resulting from inappropriate research methodologies" (p. 39). Through the lens of technical rationality, he addressed Estabrooks' earlier critique of whether RCTs and similar methodologies yield evidence that is suitable to nursing practice.

Another factor supporting the existence of the theory-practice gap is what Rolfe characterized as the "one-way flow of information from research and researchers, through academic journals and textbooks, to nursing practice and practitioners" (p. 39). This process further excludes nurses from their own practice, as "nurses are directed in their everyday practice by the writing of theorists." To address this, Rolfe recommended that nursing be practiced "as a science rather than a technical science," with research methods that account for the fact that nursing focuses on individual patient cases rather than populations. More suitable approaches include "single-case research" and "reflection in action" or "experimenting in action" (p. 40).

These recommendations move toward the concept of reflective practice, which is only implied in Estabrooks' analysis but more explicitly developed in Rolfe's discussion. Reflective practice is appropriate for nursing because it eliminates the problem of utilizing methods that tend to generalize across populations rather than probe deeply into specific nursing phenomena. Rolfe's ultimate recommendation — creating a balance between scientific method and nursing inquiry — best encapsulates the reflective practice stance. The section that follows examines this balance as elucidated by Avis (2006).

Conclusion

Analyses of the articles concerning issues about EBP showed that the main concern about this framework is its applicability to nursing practice, and the authors collectively agreed that EBP should not be implemented based solely on research information. An effective framework for nursing practice is one that combines, to quote Rolfe, both scientific method and nursing inquiry — incorporating the two essential elements of science and experience. As Avis demonstrated, both elements are present in the reflective practice framework.