What is the evidence on evidence‐based nursing? An epistemological concern

AIM: This paper adopts an epistemological perspective in order to support the assertion that there is very little evidence to support the existence of evidence-based nursing as a distinct construct or process. RATIONALE: This analysis of concept meaning is based on the theory of symbolic interactionism. By adopting this theory the commonalities and inconsistencies in the use of evidence-based symbolism by nurses and other health care professionals can be used to evaluate the perceived meaning of the term. METHODS: A frequency analysis of relevant key words in one publications data-base demonstrates the increasing use of evidence-based terminology and its euphemistic status visa vi research. An epistemological analysis is conducted on a sample of concept clarification statements taken from the popular literature, defining the nature of 'evidence' and 'evidence-based practice'. FINDINGS: The results of the frequency analysis show that the keywords 'evidence-based medicine' revealed 5612 papers, evidence-based practice (EBP) 432 papers, evidence-based nursing 47 papers, evidence-based health care 60 papers, and evidence-based decision making 43. Almost all of these papers have been published since 1995 and the earliest use of the symbol 'evidence-based' is 1992. There is also an increase in papers adopting 'evidence-based' symbolism along with a commensurate decrease in the use of the term 'research' in the nursing context. CONCLUSION: 'Evidence-based practice' is commonly a euphemism for information management, clinical judgement, professional practice development or managed care. There is insufficient evidence to demonstrate that evidence-based nursing is a single construct or process that can be distinguished from its concomitants. The term adds little more to the existing long standing traditions of quality assurance and research-based practice. Nurses must avoid the inefficiency brought about by the 'intense enthusiasm followed by sad disenchantment' that has been associated with other attempts to introduce innovation in health care delivery (Fienstein & Horowitz 1997).     

Evidence-based research in complementary and alternative medicine I: history

Contemporary Western medicine has witnessed a fragmentation of our conceptualization of the medical endeavor into 'traditional medicine' and 'non-traditional medicine'. The former is meant to refer to the Western medical tradition, the latter encompasses both 'complementary' and 'alternative' medical practices. Complementary medicine complements conventional medical treatments, and alternative modes of medical interventions are meant to replace traditional Western medicine. Evidence-based research must be directed at establishing the best available evidence in complementary and alternative medicine. This paper is the first of a set of four 'lectures' that reviews the process of evidence-based research, and discusses its implications and applications for the early decades of the 21st century. The purpose of this paper is to introduce the series by examining some of the historical and philosophical foundations of this research endeavor.     

Evidence and clinical judgement

Widespread acceptance of the neologism 'evidence-based medicine' (EBM) has had the consequences of obscuring what evidence really is, and of eroding the importance of judgement in clinical situations. In this essay I seek to correct this lack of balance in the view of clinical encounters as portrayed by EBM. A better understanding of what evidence is can be obtained by looking beyond medicine to the way in which scientists and detectives view evidence. In both spheres, the importance of judgement is emphasized, even if it is a technical type of judgement. Clinicians also employ a technical kind of judgement, similar to that in science and detective work, when assessing the evidence relating to the truth of a diagnosis for an individual patient; but judgements relating to the ongoing care and treatment of that patient are based on what Aristotle calls phronesis or 'practical wisdom'.     

An evidence-based medicine fellowship in a children's teaching hospital

This paper reports the introduction of an evidence-based medicine fellowship in a children's teaching hospital. The results are presented of a self-reported 'evidence-based medicine' questionnaire, the clinical questions requested through the information retrieval service are outlined and the results of an information retrieval service user questionnaire are reported. It was confirmed that clinicians have frequent clinical questions that mostly remain unanswered. The responses to four questions with 'good quality' evidence-based answers were reviewed and suggest that at least one-quarter of doctors were not aware of the current best available evidence. There was a high level of satisfaction with the information retrieval service; 19% of users indicated that the information changed their clinical practice and 73% indicated that the information confirmed their clinical practice. The introduction of an evidence-based medicine fellowship is one method of disseminating the practice of evidence-based medicine in a tertiary children's hospital.     

Non-linearity in clinical practice

The whole spectrum of medicine consists of complex non-linear systems that are balanced and interact with each other. How non-linearity confers stability on a system and explains variation and uncertainty in clinical medicine is discussed. A major theme is that a small alteration in initial conditions may have a major effect on the end result. In the context of non-linearity, it is argued that 'evidence-based medicine' (EBM) as it exists today can only ever be relevant to a small fraction of the domain of medicine, that the 'art of medicine' consists of an intuitive 'tuning in' to these complex systems and as such is not so much an art as an expression of non-linear science. The main cause of iatrogenic disease is interpreted as a failure to understand the complexity of the systems being treated. Case study examples are given and analysed in non-linear terms. It is concluded that good medicine concerns individualized treatment of an individual patient whose body functions are governed by non-linear processes. EBM as it exists today paints with a broad and limited brush, but it does promise a fresh new direction. In this context, we need to expand the spectrum of scientific medicine to include non-linearity, and to look upon the 'art of medicine' as a historical (but unstated) legacy in this domain.     

Evidence-based vs. Eminence-based Medicine in der Orthop?die

Evidence-based and eminence-based medicine are terms in modern medicine which provide the rational fundamentals of medical practice and substantially contribute to the state of knowledge in a complementary way. Under scientific considerations, evidence-based medicine demands evidence and proof for medical diagnostics and therapeutics, while eminence-based medicine relies on expert opinions and experiences. However, the latter may not mandatorily correspond with the criteria of evidence-based medicine. Important tools of evidence-based medicine are the so-called levels of evidence and the grades of recommendation. Both classifications help to critically evaluate the scientific literature and to establish standards and guidelines in medicine. Finally, the patient should profit from the knowledge of evidence-based and eminence-based medicine.     

循证检验医学

在当今倡导证据指导下的医疗行为及医疗决策的时代，分析检验医学存在的问题，讨论将循证医学的理念引入检验医学的必要性及可行性，探索循证检验医学实践的途径，以使检验医学跟上临床医学的最新发展步伐，提供以病人为中心的最佳实验医学技术及实验医学服务。     

Evidence-based practice and the limits of rational rehabilitation

Both the American Congress of Rehabilitation Medicine and the field of physical medicine and rehabilitation have entered an age of evidence-based rehabilitation. Despite some concerns over the difficulties in applying the methods of evidence-based practice to rehabilitation research, there is little question that we will continue to move in this direction. This will also require the translation of scientific evidence into clinical practice. Rather than representing opposing approaches to practice, the integration of the best available scientific evidence with clinical experience and judgment represent 2 of the pillars of evidence-based practice. However, we also need to recognize the subjective nature of clinical decision making as a fundamental aspect of human judgments. Finally, we need to acknowledge the subjective meanings of illness and disability to the patients we serve. Any efforts to build our practice based on the best available systematic evidence are unlikely to succeed unless we include patients values and beliefs and incorporate this perspective into our rehabilitation research. This aspect of evidence-based rehabilitation raises important questions about our fundamental roles and how we will choose to practice and define our field in the future.     

循证医学与临床实践

目前循证医学方法学已广泛应用于临床医疗实践,指导、制定临床各科疾病的治疗方案,评价药物、治疗方案的有效性、适用性,以及为政府部门制定卫生政策、新药的研究、开发评价提供证据,并已形成了许多相关学科。介绍循证医学对临床医疗、中医药发展和药学研究的影响及其临床指导作用,提倡在临床医疗实践中,充分应用循证医学的原则与方法,为临床、科研、卫生决策、医学教育提供最佳证据,并应用最佳证据指导临床决策。     

Ideas and ideals in medicine: fruits of reason or props of power?

Editors of medical journals play a central role in the promotion – or suppression – of ideas and ideals in medicine. Recently eminent among these have been the advocacies of the Evidence-based Medicine (EBM) movement and colleagues concerned with evidence and guidelines for health care. With regard to these topics, it still remains for editors of journals either to advance or to retard even the consolidation of the associated core concepts, most notably those of evidence in medicine, scientific medicine, and rational medicine. I present, first, a case study on the conduct of the editors of three medical journals, specifically their assumption of the role of authority on the scholarly fundamentals of evidence in medicine and their responding to propositions on the topic with commentaries well below the intellectual standards that should prevail in the journals of a learned profession. Then, following a brief review of the Flexnerian and EBM ideas and ideals on the practice of medicine, supplemented by observations drawn from medical sociology and the precepts of the philosophy of science, I posit a way of understanding such behaviour by editors of medical journals. They can have a temptation, and apparently some propensity, to play a regressive role in the development of the fundamentals of medicine. This is prone to occur whenever reason constitutes a threat to power, whether solely to the editors' own or to that of the profession at large. A full realization of the dream of reason in medicine requires an immense integrity of its journal editors and of its other intellectual leaders.     

证据的来源与检索

循证医学是指认真、明确和明智地应用现有的最好证据,同时结合医生的个人专业技能和临床经验,考虑病人的愿望,对患者做出医疗决策.因此证据及其质量是循证医学的关键.本文旨在系统介绍证据的来源和如何检索证据,为卫生健康工作者的循证医学实践提供服务和帮助.     

Evidence-based medicine and its role in ethical decision-making

The recent emergence of evidence-based medicine (EBM) presents medical ethics with the challenge of analyzing what is the current best medical evidence in ethical decision making. This article concludes that the use of the best available, most recently published research findings is a primary moral obligation. However, this does not automatically mean that the use of these research findings will lead to better ethical decision making. Research data can be distorted by methodological failings in the design and reporting of experiments, or by technical and commercial bias. Moreover, the introduction of norms, values, principles and ethical theories can lead to other choices than those proposed by empirical research findings. Ethical decision making must be informed and legitimated by the best available medical research. Nevertheless, ethical decision making is still primarily a choice based on values and norms.     

Evidence-based medicine: a Kuhnian perspective of a transvestite non-theory

Evidence-based medicine (EBM) has been presented by its protagonists as a new paradigm for medical practice. In this article that claim is analysed through the theory of scientific development proposed by Thomas S. Kuhn in 1962. Traditional medical paradigms are discussed, as well as the assumptions of the supposedly ‘new’ paradigm of EBM. The value of the results of randomized clinical trials (RCTs) for the elaboration of clinical guidelines is analysed within the context of the assumptions of EBM and the paradigm concept of Thomas S. Kuhn. It is argued that the results of RCTs, whenever contradicted by fundamental medical theory, constitute inadmissible evidence for the development of clinical guidelines. The supremacy of results of clinical trials over traditional medical paradigms, advocated by the protagonists of EBM, is rejected. Fundamental contradictions of EBM are also exposed: the fact that there is no evidence to support the utility of EBM and its call for a new type of authoritarianism in medicine. Finally, it is suggested that ‘epidemiology-based medical practice’ is a better, rhetoric-free designation for what is currently termed evidence-based medicine*. It is concluded that EBM is not what it claims to be and that its assumptions are simply irrational.     

Evidence-based laboratory medicine as a tool for continuous professional improvement

BACKGROUND: Evidence-based medicine (EBM), defined as "the conscientious, explicit, and judicious use of the current best evidence in making decisions about the care of patients," seems a tool (a "new paradigm") able to meet individual clinical experience with robust observations. EBM has been driven by the need to manage information overload by cost control and by public request for the best in diagnostics and treatment. METHODS: The application of EBM in laboratory medicine or evidence-based laboratory medicine (EBLM) is aimed to advance clinical diagnosis by researching and disseminating new knowledge, combining methods from clinical epidemiology, statistics, and social science with the traditional pathophysiological molecular approach. RESULTS: EBLM, by evaluating the role of diagnostic investigations in the clinical decision-making process with emphasis on measurable outcome, can help both in improving the quality of new scientific findings and in translating the results of good-quality research into everyday practice. CONCLUSIONS: Since there is a need to integrate many educational tools to focus the strategy on promoting the implementation of best practices, the STARD proposal for robust diagnostic test primary studies, the presence of systematic reviews of high quality, and the development of valid guidelines based on the best scientific evidence may be useful to promote an a evidence-based culture for appropriateness, efficiency, and effectiveness in laboratory medicine.     

Evidence-based laboratory medicine

Evidence-based medicine (EBM) is a method for solving problems concerning the assessment of laboratory testing in patient care. Practising EBM involves the use of the available evidence to make health care decisions. The best way to practice EBM is the development, validation and implementation of guidelines. Guidelines are considered as the process by which healthcare research and experience are translated into improved patient care. In laboratory diagnostics EBM can be best demonstrated in high-prevalence conditions. Because of the number of patients encountered, high-prevalence conditions have a greater impact on patient morbidity and health care expenditure. In evidence-based laboratory medicine the best evidence comes from systematic reviewing studies of diagnostic tests. The reviewing of diagnostic trials and the development of good practice guidelines on the basis of these studies must be an important task of the scientific associations of clinical chemistry and laboratory medicine.     

Evidence‐based medicine as science

Evidence‐based medicine has claimed to be science on a number of occasions, but it is not clear that this status is deserved. Within the philosophy of science, four main theories about the nature of science are historically recognized: inductivism, falsificationism, Kuhnian paradigms, and research programmes. If evidence‐based medicine is science, knowledge claims should be derived using a process that corresponds to one of these theories. This paper analyses whether this is the case. In the first section, different theories about the nature of science are introduced. In the second section, the claim that evidence‐based medicine is science is reinterpreted as the claim that knowledge claims derived from randomized controlled trails and meta‐analyses are science. In the third section, the knowledge claims valued within evidence‐based medicine are considered from the perspective of inductivism, falsificationism, Kuhnian paradigms, and research programmes. In the final section, possible counter arguments are considered. It is argued that the knowledge claims valued by evidence‐based medicine are not justified using inductivism, falsificationism, Kuhnian paradigms, or research programmes. If these are the main criteria for evaluating if something is science or not, evidence‐based medicine does not meet these criteria.     

On the challenges of using evidence-based information: the role of clinical uncertainty

Evidence-based medicine helps physicians appraise the latest and best evidence and incorporate patient's values in reaching a shared clinical decision. However, many decisions in medicine are made in the paucity of best evidence. Medical uncertainty remains inherent in clinical practice and contributes to significant variability in the way physicians and patients manage medical problems. Physicians and patients have varying degrees of tolerance for uncertainty. Intolerance to uncertainty among physicians results in increased test ordering tendencies, variability in medical treatment, failure to comply with evidence-based guidelines, and even guide career choices. Factors that result in the variability of physicians' interpretation of an effective treatment include: patient factors (prioritizing some factors over others), physician factors (lack of knowledge, lack of resources, medical uncertainty), and environmental factors (limitation of time and practice). Several approaches that have been found useful in implementing evidence in clinical practice include: sending reminders to prompt physicians to perform patient-related clinical activities, introducing computer information systems to support practice, and using interactive education interventions to teach newer skills and challenge negative attitudes. Passive educational approaches, like dissemination of guidelines and didactic lectures, are usually less useful in changing behavior. Among the techniques found to be useful for managing uncertainty are shared decision making, meticulous history taking, and physical examination, excluding worrisome differential diagnosis and establishing trust in patients. The role of future studies in assessing the outcome of multiple evidence-based strategies in situations of medical uncertainty remains to be explored.     

Single case study and evidence-based practice

Single case study and evidence-based practice With the current emphasis upon evidence-based medicine in statutory health care provision in the UK, mental health nursing is challenged to justify its approaches. Psychological theories, once taken for granted in mental health nursing, are now being challenged by new definitions of evidence. In this paper the authors focus upon the use of individual case study. The discussion questions the validity of applying the hierarchies of evidence proposed by evidence-based medicine to mental health nursing theory and practice. The role of case study as the prime source of evidence is argued and is justified in mental health nursing research and practice.     

Mere anecdote: evidence and stories in medicine

In evidence-based medicine, randomized controlled trials are said to be the highest evidence of what works, while anecdotes have low value or are not even considered to be medical evidence. Similar hierarchical views of evidence have infected other disciplines, including evidence-based education and evidence-based government. Here, I explore the artificial divisions of acceptable from unacceptable evidence, numbers from narrative and sciences from humanities. I challenge the deprecation of stories in medicine. Some stories are based on experiments while others are based on more or less plausible theories. Some stories offer vast and impressive statistics gathered from many observations while others present one noteworthy event. Published reports are themselves stories of what experimenters did. Systematic reviewers generate their own observations of collected stories of experiments. Reviewers of systematic reviews in turn report their observations of systematic reviews. All of these stories become evidence of what works in medicine.     

The need for traditional Chinese medicine morbidity research

Traditional Chinese medicine (TCM) has long justified its practice on empirical phenomenology. Questions remain, however, as to the legitimacy of this approach and its relevance to TCM practice and educational developments in the 21st century. General medical practice (GMP) has used practice-based data collected over the past 25 years to develop relevant medical curriculum and enhance patient care. As TCM becomes ever more incorporated into Western educational and health systems, it too must concern itself with providing a solid evidence base to be used in enhancing patient care and educational curriculum. Computer generated data related to patient problems or problem complexes abstracted from TCM clinical records can provide the basis for practitioner development and the enhancement of training programs that will lead to improvements in patient care. Such locally valid and representative data can also be used to inform research programs, public policy and evidence-based commissioning. The key to developing such systems is standardising TCM terminology and data collection protocols.