The struggle for safe staffing levels in the USA: A political economy of evidence-based practice

This paper examines the debate over nursing staff to patient ratios through the lens of Marxist political economy, arguing that the owners and controllers of healthcare in the USA have a vested interest in opposing mandated minimum ratios, while those involved in carrying out nursing care have a vested interest in their implementation, which coincides with the interests of patients. We examine how evidence-based practice articulates with social power, and proceed to interrogate the research methods used to generate evidence for practice, noting that randomised controlled trials are not suitable for evaluating nurse/patient ratios, which means that observational studies are the primary source of evidence. Representatives of nursing managers have used the fact that observational studies, while demonstrating an association between high ratios and poor outcomes, have not established a causal relationship, to support their argument that there is not sufficient evidence for the imposition of mandatory ratios. We argue that the precautionary principle provides firm justification for mandatory ratios, unless and until a causal relationship has been disproved. We conclude that those involved in the generation of evidence have to choose between technical arguments about the inferiority of observational studies, or emphasising their sufficiency in triggering the precautionary principle.

Post-trauma: Is evidence based practice a fantasy?

Trauma, bereavement, and loss are universal human experiences. Much has been written about the process that the bereaved go through following the loss of a loved one. Recent events such as 9/11, earthquakes in Turkey, genocides in Rwanda, community conflict in Northern Ireland, and the Asian Tsunami Disaster have drawn unprecedented public attention to the subject of traumatic bereavement. Increasingly, it is recognised that while most people are able to cope with loss generally by eventually restructuring their lives, those bereaved in traumatic circumstance often find it extremely difficult. As a consequence, a plethora of interventions have emerged, however, to-date, little is know about their actual effectiveness in helping the bereaved. With the emphasis of health and welfare professions on evidencebased practice (EBP) greater than ever and a raising awareness of accountability as key element of ethical practice, the call for EBP in traumatic bereavement is compelling. Using examples from work carried out in Northern Ireland, we look at the backdrop of the issues involved, describe some of the most commonly used therapeutic interventions, and explore the possibility of evidence-based practice.

The postmodernist war on evidence-based practice

In this paper, we examine the war of words between those who contend that health care practice, including nursing, should primarily be informed by research (the evidence-based practice movement), and those who argue that there should be no restrictions on the sources of knowledge used by practitioners (the postmodernists). We review the postmodernist interventions of Dave Holmes and his colleagues, observing that the postmodernist style to which they adhere, which includes the use of continental philosophy, metaphors, and acerbic delivery, tends to obscure their substantive arguments. The heated nature of some responses to them has tended to have the same effect. However, the substantive arguments are important. Five main postmodernist charges are identified and discussed. The first argument, that the notion of ‘best evidence’ implies a hierarchical and exclusivist approach to knowledge, is persuasive. However, the contention that this hierarchy is maintained by the combined pressures of capitalism and vested interests within academia and the health services, is less well founded. Nevertheless, postmodernist contentions that the hierarchy embraced by the evidence-based practice movement damages health care because it excludes other forms of evidence that are needed to understand the complexity of care, it marginalizes important aspects of clinical knowledge, and it fails to take account of individuals or their experience, are all seen to be of some merit. However, we do not share the postmodernist conclusion that this adds up to a fascist order. Instead, we characterize evidence-based practice as a necessary but not sufficient component of health care knowledge.

Fundamental patterns of knowing in nursing: The challenge of evidence-based practice

This article reconsiders the fundamental patterns of knowing in nursing in light of the challenge of narrowempirics in the formof evidence-based practice. Objections to the dominance of evidence-based practice are reviewed, and the reasons for it are examined. It is argued that it is partially the result of weaknesses in the alternative patterns of ethical, personal, and esthetic knowing, the ineffability of which compromises accountability. This ineffability can be countered only by introducing a wider form of empirics than countenanced by evidencebased practice into all patterns of knowing, to demonstrate their salience and to make their use in practice transparent.

Evidence-based Practice in Cognitive-Behaviour Therapy

book review

Cancer Cachexia Care: The Contribution of Qualitative Research to Evidence-Based Practice

Background: Despite its prevalence and prognostic impact, primary cachexia is not well understood. Its potential to cause considerable psychological stress indicates the need for qualitative research to help understand the perspectives of those affected.

Objective: The aims of this study were to describe the perspectives of patients with primary cachexia, of their relatives, and of the healthcare professionals involved in their care and to demonstrate how this evidence can be applied in practice at 4 different levels of application ranging from empathy to coaching.

Methods: A review of the qualitative literature and empirical qualitative investigation was used to understand the experiences of patients and relatives and the perspectives of professionals.

Results: The main worries expressed by patients and relatives concerned appetite loss, changing appearance, prognosis, and social interaction. We also describe their coping responses and their views of professionals’ responses. The main concerns of professionals related to poor communication, lack of clinical guidance, and lack of professional education.

Conclusions: Understanding patients’, families’, and professionals’ perspectives, and mapping that understanding onto what we know about the trajectory and prognosis of the condition, provides the evidence base for good practice. Qualitative research has a central role to play in providing the knowledge base for the nursing care of patients with cachexia.

Implications for Practice: The evidence provided can improve nurses’ insight and assist them in assessment of status, the provision of guidance, and coaching. There is a need for the development of a holistic, information-based integrated care pathway for those with cancer cachexia and their families.