empirical nursing: the art of evidence-based care

(1)

(2)

EMPIRICAL NURSING

(3)

This page intentionally left blank

(4)

EMPIRICAL NURSING: THE ART OF EVIDENCE-BASED CARE

BY

BERNIE GARRETT, PhD, RN

University of British Columbia School of Nursing, Vancouver, Canada

United KingdomNorth AmericaJapanIndiaMalaysiaChina

(5)

Emerald Publishing Limited

Howard House, Wagon Lane, Bingley BD16 1WA, UK First edition 2018

Copyrightr2018 Bernie Garrett. Published under exclusive licence.

Reprints and permissions service

Contact:[email protected]

No part of this book may be reproduced, stored in a retrieval system, transmitted in any form or by any means electronic, mechanical, photocopying, recording or otherwise without either the prior written permission of the publisher or a licence permitting restricted copying issued in the UK by The Copyright Licensing Agency and in the USA by The Copyright Clearance Center. Any opinions expressed in the chapters are those of the authors. Whilst Emerald makes every effort to ensure the quality and accuracy of its content, Emerald makes no representation implied or otherwise, as to the chapters’suitability and application and disclaims any warranties, express or implied, to their use.

British Library Cataloguing in Publication Data

A catalogue record for this book is available from the British Library ISBN: 978-1-78743-814-9 (Print)

ISBN: 978-1-78743-813-2 (Online) ISBN: 978-1-78743-988-7 (Epub)

Certificate Number 1985 ISO 14001

ISOQAR certified Management System, awarded to Emerald for adherence to Environmental standard ISO 14001:2004.

(6)

I dedicate this book to Alison, Natalie and Rachel, who provided love, support, encouragement and inspiration, but above all, excellent practical advice.

(7)

(8)

List of Figures

Chapter 5

Figure 1: Reiﬁcation.. . . 88

Figure 2: The Hermeneutic Circle. . . 94

Chapter 6 Figure 3: The Pyramid of Evidence for EBP. . . 135

Figure 4: The Cochrane Collaboration Logo. . . 136

Figure 5: The Distribution Bell Curve and Standard Deviation. . . 160

Figure 6: H₀Probability Critical Region,α=5%. . . 168

Figure 7: Conﬁdence Intervals Depicted on a Bar Chart with Two Results: The Red Bars. . . 175

Chapter 7 Figure 8: The Checkerboard Illusion. . . 189

Figure 9: The Wason Selection Task.. . . 193

Figure 10: The Solomon Asch Test Example. . . 196

Chapter 9 Figure 11: The Client. . . 241

(11)

(12)

List of Tables

Chapter 2

Table 1: Inductive, Deductive and Abductive Reasoning. . . 17

Chapter 4 Table 2: Classiﬁcation of D-N-related Explanatory Laws. . . 58

Chapter 6 Table 3: Different Models of EBP Implementation. . . 134

Table 4: Alternatives to Reliability and Credibility for Qualitative Work. 147 Table 5: Key Sampling Terms. . . 162

Table 6: Non-Probability Sampling Techniques.. . . 162

Table 7: Probability Sampling Techniques. . . 164

Table 8: Advantages and Disadvantages of Probability and Non-Probability Sampling. . . 165

Table 9: Key Points to Consider for Sampling. . . 166

Table 10: Hypothesis Testing. . . 169

Table 11: Odds Ratio Calculation. . . 173

Chapter 7 Table 12: Cognitive Bias. . . 198

Table 13: The Monty Hall Problem Tabulated.. . . 200

Table 14: Epidemiological Malaria Test Statistics. . . 202

Chapter 9 Table 15: An Empirical Nursing Assessment Framework. . . 245

Table 16: A Care Plan Exemplar.. . . 250

(13)

(14)

Foreword

I’m writing this forward on a hot summer’s day in England on what has been something of novelty for us a two-week-long heatwave! At least, there’s no need to worry about my vitamin D levels. Isn’t it interesting how certain triggers create a certain responses in our brains? Sunshine and vitamin D, carrots and night vision, cranberry juice and urinary tract infections, gluten and allergies, MMR vaccinations and autism. I wonder what your reaction is to some of these?‘That’s an old wives’tale’perhaps? Maybe‘oh yes, my grandmother used to say that’? Or, for some, ‘Hang on! We know that isn’t true?’ In some instances, the responses can be instantaneous, as if on autopilot. What is that drives these responses? Using scientiﬁc experimentation, Kahneman and Tversky (2000) described this psychological phenomenon of the brain, introduc- ing to us the study of cognitive biases and the idea of slow and fast thinking.

They provided ways to show us this in action too. Take the following example:

A bat and ball cost£11 in total and the bat costs£1.00 more than the ball. How much does the ball cost? The ﬁrst time I saw this ‘£10’ also instantaneously popped into my head (the answer is £5). Being mindful of our own cognitive biases and what anchors them is theﬁrst step in understanding how they impact the way we assimilate knowledge. And no less so for professions that involve applying knowledge in the care of somebody’s health.

Exploring our knowledge of what’s ‘good’or‘bad’for our health inevitably takes us to advances in research and evidence-based health care. Such advances have allowed us to do away with‘old wives’tales’and healthcare practices once thought to be good for us. There are examples abound: starving for a fever, cocaine for treating depression, putting babies to sleep on their fronts to prevent choking-related death, complete bed rest following surgery or giving oxygen as soon as possible after a heart attack. Practices now known, through scientiﬁc research, to cause more harm than good for most are no longer routinely advised or practiced.

However, there are two sides to the coin. The misuse of science can, and does, lead to harm and we need to be ever mindful of this. For many, the words

‘Andrew Wakefield’will trigger a very fast response. But it may not be the one you just had. I read in the news recently that there had been an outbreak of mea- sles in the city of Bristol. And not an incidence isolated to one city in the UK. It appears at least some people have been anchored to the original ideas of Wakefield that were rapidly and widely disseminated, and recently amplified via new and all-pervading media avenues, resulting in real harm.

The introduction of evidence-based medicine in the early 1990s shone a light on the way healthcare professionals made decisions.‘That’s how we’ve always done it’,‘It makes sense’and mechanistic reasoning dominated. This is not to

(15)

say that patient care and well-being weren’t at the heart of their decisions; it’s just that how these decisions were made wasn’t really questioned before. Basing them on good scientiﬁc evidence it turned out was low down the list of priorities.

Its introduction also led to the need for new skills. The development of evidence-based practice has continued apace, and at its most basic represents the skill of debunking, and the art of understanding and relaying the uncertainties of scientiﬁc evidence. All health professionals should have this skill, as Paul Glasziou et al. (2008). ‘A twenty-ﬁrst-century clinician who cannot critically read a study is as unprepared as one who cannot take a blood pressure or exam- ine the cardiovascular system’. This applies to all health professionals, including nurses.

In an informative and accessible way, the author explores the nature and philosophy of science and the practice of evidence-based health care. In the first chapter, he explores and expands some of the themes previously mentioned, particularly the worrying trend of public scepticism in science, driven by‘fake news’ and celebrity-based medicine and the pivotal role nurses play in dispelling myths, both old and new, and ensuring their patients are informed by the best available scientific evidence. In Chapter 2, he provides a detailed overview of key epistemological theories; their origins, examples of their applications, discussion of relative their strengths and weakness, and the nature of science, challenging the reader to consider them in the context of their own practice and knowledge acquisition. These chapters are a crucial introduction, before the author moves on to discuss some fundamental aspects of science, including causality, its alternative approaches and the social sciences, highlighting inherent deficiencies within each and the active efforts to address them. Throughout, the ideas explored are summarised and placed in an evidence-based context, ensuring relevance and interest to all practitioners.

Readers willﬁnd Chapter 6 particularly useful as this is where the knowledge and skill of evidence-based practice is introduced. In a lucid manner, the author provides excellent explanations of the key concepts that underpin health research that will be of great use to those with limited knowledge, while acting as a great reminder to those more familiar with them. The author should also be praised for discussing some of the criticisms of evidenced-based practice and how to address them. As already stressed, this knowledge is vital in modern health care and a skill that all involved in this area should have. This book will provide you with it.

Bad science and ways to challenge it are the focus of the latter chapters. The rise of pseudoscience as a rational and realistic alternative is particularly prevalent in health science. As a health practitioner, there will undoubtedly be times when you will need to discuss the wishes of a patient who has inadvertently succumbed to some news story of a new, non-scientiﬁc approach. In such times, you will need to use your debunking skills, and this chapter acts as great base for developing them. He concludes with a consideration of the art of nursing practice based on science and evidence in the context of knowledge generation and effective practice.

xiv Foreword

(16)

The author leans frequently on the work of Bertrand Russell, as too will I in summary:

The art of basing convictions on evidence, and of giving them only that degree of certainty which the evidence warrants, would, if it became general, cure most of the ills from which this world is suffering.

This book will serve you well in your development as an artist of evidence- based practice.

David Nunan, June 2018 Lecturer and Senior Research Fellow Nufﬁeld Department of Primary Care Health Sciences University of Oxford

References

Glasziou, P., Burls, A., & Gilbert, R. (2008). Evidence based medicine and the medical curriculum.British Medical Journal,337, a1253.

Kahneman, D., & Tversky, A. (Eds.) (2000).Choices, values and frames. New York, NY: Cambridge University Press.

Foreword xv

(17)

(18)

Preface: Using this Book

While the author would like to assume readers will ponder on every word of this book in great detail, the reality for most time-pressed nurses is that they will want to use it as a reference text to explore specific ideas at particular times, as theyfind necessary. Therefore, this book has been designed for use in different ways: as a textbook, a reference source, or as a concise guide and primer to scientific thinking and its application in nursing. The blend of art and science that makes up nursing is explored with the aim to emphasise the value of creative scientific thinking for practical nursing issues and understanding how to avoid the pitfalls of non-science, pseudoscience, and even bad science along the way. Even those already familiar with scientific epistemology may find some interesting arguments and challenges to their foundational beliefs.

Although the book covers a wide range of philosophical approaches in nursing, it is not designed as a comprehensive philosophy text. Given the great volume of manuscripts devoted to this subject throughout the history of civilisation, it would be presumptuous to hope to do more than explore the fundamental concepts in a text of this nature. References to further readings and sources are given for the reader who wants to know more. Assume that you will encoun- ter new ideas and terminology as you read, and you should expect the need to explore other sources. Readers who want to quickly get to grips with such terms as ontology, dialectic, nominalism, hermeneutics or gnostic can ﬁnd a quick reference in a glossary of key terms included at the end of the book and an extensive index.

This text together with the references supplied, and excellent sources now available on the Internet, should enable the reader to understand the key concepts and arguments. In addition, a simple“Good Science Detection Guide”is included in the appendix to aid in the identiﬁcation of the good, the bad, pseudoscience and non-science in healthcare writing and research. Summary ideas for critical discussion are also presented at the end of each chapter that may be helpful for those teaching this material.

Finally, it is also acknowledged that any book exploring this subject cannot be value-free, and therefore, a particular perspective on philosophy and nursing is presented here that aligns with empiricism, and contemporary science, and one that I hope readers willﬁnd compelling.

Bernie Garrett June 2018

(19)

(20)

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 (19181988)

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 cov- ered 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 byfine 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

(21)

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 per- ceived 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 2 Empirical Nursing: The Art of Evidence-based Care

(22)

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 Science and NursingWhy Should I Care? 3

(23)

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 criti- cized 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 in2009, 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 collec- tive 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 4 Empirical Nursing: The Art of Evidence-based Care

(24)

pencil and paper also represents a technology. Ever since humansfirst began to use tools, technological advancement has progressed. For our purposes, technology may be considered as the application of products from thefindings 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 (460370 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, tubercu- losis, 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 thefirst powered aircraft hadflown. 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 exponen- tial 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 Science and NursingWhy Should I Care? 5

(25)

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, exer- cise, and smoking on cardiovascular and respiratory diseases. These rapid devel- opments 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 qualiﬁca- tion 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 (18201910) gives a good example of the scientific practice of direct observation and hypothesis with her suggestion to an unheed- ing 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 identifying support for an empirical basis for nursing care at the onset of our professional organization.

Nursing’s disciplinary focus is of course, very different from medicine, in that nurses focus on patient/client care and health rather than the treatment and ame- lioration of illness and disease. Most nurses are motivated to enter the profession speciﬁcally with a desire to attain the knowledge, practical skills and attitudes that will allow them to help people improve their health status and maximize their quality of life, or when this is not possible to help them to die peacefully and with dignity. And here lies the most fundamental difference between nursing and medicine as distinct disciplines. Whilst medicine has identiﬁed a clear and 6 Empirical Nursing: The Art of Evidence-based Care

(26)

distinct focus on preserving health by diagnosing, treating and preventing disease using a biomedical model, adopting an empirical scientiﬁc framework, nursing has adopted more behavioural models of health and struggled with a foundational philosophy, as human behaviour, care, quality of life and health are by their very nature more complex multi-faceted concepts. Historically, the development of nursing has also had a strong link with theology, particularly the ideas of giving service and aiding the sick, and this can be seen as reﬂected in the contemporary work of nursing academics exploring ontology, the nature of being or existence. This has become a more prevalent trend amongst nursing theorists over the last 25 years with some novel conceptual frameworks for nursing being suggested, Parse’s human becoming theory being a key example (Parse, 1992). Much of the recent development in nursing theory and research has also incorporated an increased focus on alternative post-modern and femi- nist philosophical approaches with the further alignment of nursing with the humanities, in the desire to develop a unique disciplinary body of knowledge.

Following trends in the social sciences and arts has led to the promotion of the ethos in nursing academia that nursing science has evolved further from traditional positivist science to a broader humanistic interpretation. However, on closer inspection, this represents a rather simplistic exploration of these issues and of the current state of scientific philosophy. It has even been questioned whether contemporary nursing science as envisaged can legitimately be considered a science at all (Winters & Ballou, 2004). The nature of this argument and different viewpoints as to what actually constitutes modern scientific inquiry and nursing will be explored further in this chapter. There is a sound case to be made that nursing should be underpinned by scientific knowledge, but it is also foremost a practical profession concerned with action (or praxis) rather than theory.

Nursing Praxis

The ancient Greeks identiﬁed three basic human activities: theoria (focused on knowledge leading to truth), poeisis (focused on creation and production) and praxis (focused on enacting skills and action). Both Aristotle and Plato used the word‘praxis’ to describe the activity engaged in by people where the end goal was action. And Aristotle also identiﬁed praxis could be good (eupraxia) or bad (dyspraxia) depending on the knowledge and, of course, skill of the practitioner.

This necessitates some notion of moral reasoning or phronesis, to establish what is considered good in a given situation.

The nature of praxis has occupied the thoughts of many philosophers over the years from Immanuel Kant to Martin Heidegger. Karl Marx discussed it in that he suggested the purpose of his political philosophy was to understand and change the world rather than simply explain it, (Marx & Engels, 1965) whilst Paulo Freire suggested praxis required a process of reﬂecting upon the world followed by action to transform it (Freire, 1973). It can be argued that nursing is a form of praxis in that it is a practice-based discipline, and in that nurses are Science and NursingWhy Should I Care? 7

(27)

concerned with the application of practical therapeutic techniques to maximize health and minimize suffering, and positive action rather than simply academic inquiry with a focus on theory rather than action.

If the profession of nursing is a form of praxis, it follows nurses should be concerned with what knowledge is required to inform this praxis, support eupraxis and avoid dyspraxis. This in turn leads us to consider, what the nature of this knowledge should be, and from a pragmatic approach, what epistemological foundations of nursing knowledge are most likely to result in eupraxis. In other words, how should nursing knowledge be generated and used by nurses to best maximize positive health outcomes for patients or clients? This then is the central question behind our concern with the nature of nursing knowledge (nursing epistemology) and ongoing struggles within nursing academia to deﬁne nursing phenomena and knowledge and its relation to science.

Pragmatism and its Value for Nursing

In exploring modern scientific thinking and its relationship to nursing, a key theme encountered is the value of a pragmatic approach. Pragmatism presents an approach thatfits very well with the principles of praxis in nursing and in a contemporary scientific approach to nursing knowledge. The term is derived from the same Greek word ‘pragma’, meaning action, from which the words

‘practice’and‘practical’are derived. Rather than trying to explain the nature of reality (metaphysics), a common target for philosophers, pragmatism instead tries to explain, humanly, how the relationship between the individual and their knowledge works in the practical everyday world. Pragmatism involves the idea of the theory being derived from practice and then reapplied to practice in different contexts, with the aim to support and improve it, and that theory is essential for more effective practices to develop.

The origins of pragmatism are generally credited to Charles Sanders Peirce (18391914), who is one of the founders of modern statistics and coined the term in an article entitled,How to Make Our Ideas Clear(Peirce, 1878). In its simplest terms, pragmatism purports that something is true only insofar as it works and considers practical consequences or real effects to be vital compo- nents of both meaning and truth. Pragmatists assert that the scientiﬁc method is best suited to theoretical inquiry, but that any theory that proves itself more suc- cessful in predicting and controlling our world than others can be considered to be nearer the truth and more valuable. However, there remain very different interpretations of pragmatism; some suggesting truth is inconsistent or relative.

This will be discussed further when pragmatism is explored in more detail in Chapter 4. Overall, a pragmatic approach to epistemology has value for nursing, since it is outcome focused and clearly acknowledges the changing state of human knowledge and the limitations of cognitive processes in understanding the world. These ideas reﬂect modern scientiﬁc philosophy very well and, it can be argued, provide a more substantive basis for nursing practice, with nursing 8 Empirical Nursing: The Art of Evidence-based Care

(28)

identiﬁed as a pragmatic profession focused on action but underpinned by science as the basis for its theoretical support.

Making Sense of Nursing Theory

Nursing is a unique mixture of both science and art and represents a discipline that embraces both in its practice. Nursing knowledge requires grasp of a wide range of theory in addition to practical techniques. For example, understanding of the theoretical pharmokinetics of a therapeutic medication, the behavioural psychology concerning compliance and the sociological implications for medi- cating the patient with this drug. Artistry can be clearly seen in skills involving psychomotor and cognitive techniques requiring the development of ability through practice, with which a degree of mastery can be obtained (Benner, 1984), for example, patient assessment and communication skills. Of course, artistry in nursing may be demonstrated in many other areas such as creativity and problem-solving. A professional nurse requires signiﬁcant education and training to develop such knowledge, skills and attitudes, and the body of theoretical knowledge supporting the discipline of nursing is dynamic and rapidly changing.

Given the hugely expanding knowledge base in nursing and the associated plethora of jargon readily apparent in social sciences and nursing, it is important for us to present ideas in meaningful ways. I would argue that the task of the educator is to explain complex ideas in as simple and practical terms as possible, rather than the converse; to which approach, alas, I note many modern nursing academics seem to subscribe. It is important for nursing theorists to attempt to present ideas in as plain a language as possible rather than obfuscate it with con- trivance and unintelligible jargon in an attempt to appear innovative and more erudite. Using technical terminology is certainly not to be avoided, but it makes sense to use technical terms only where they readily convey an idea in a more succinct manner than other available terms or meaningfully describe a new phenomenon.

Nursing academics should desist from using jargon unnecessarily or combin- ing adjectives and verbs together that make little sense to the uninitiated (rest assured there are someﬁrst-rate examples of this later on in the book). In this approach, we are in the excellent company of Einstein who suggested that if you can’t explain an idea to a six-year-old, you probably don’t understand it that well yourself. This seems sage advice.

Summary

Overall, this book presents an epistemological framework that is commensurate with modern evidence-based health care and serves as a solid foundation for nursing theory as a distinct body of knowledge within it. It presents an argument for modern, creative science as a productive way for nursing to further develop its knowledge base and for nurses to maximize their impact on society as healthcare professionals. In order to care for patients most effectively, nurses need to Science and NursingWhy Should I Care? 9

(29)

adopt a pragmatic stance and not be focused on which ideas and explanations represent truth, but which approaches and arguments best describe phenomena given our current state of knowledge; or if they don’t, what other ideas or theories could explain them. This forms the basis for modern thought in clinical practice. Despite all of its problems, modern science still provides the most useful and practical approach for us to understand health phenomena and a basis for providing high-quality care.

By now you will have gathered this book itself takes a particular perspective and other viewpoints are available and should also be considered by the reader.

However, I hope that the arguments and ideas presented here will help inform the reader in their quest to understand nursing theory and research and help improve practice. The following chapters develop this theme and explore why nurses should consider the rich history of scientiﬁc philosophy, the value of science for nursing and consider how alternative viewpoints have inﬂuenced the profession.

Key Points for Further Discussion

• How does scientiﬁc philosophy apply to nursing practice? Is nursing more art or science?

• Can one be an effective nurse without using a scientiﬁc rationale for nursing action?

• What are the implications of nurses not understanding of scientiﬁc philosophy for patients or clients?

• Can you think of think of an example where pseudoscience or simply bad science has negatively affected patient care, and what were the reasons behind this occurrence?

• What does praxis mean in nursing terms?

• Is pragmatism useful for an approach to nursing?

• Does the scientiﬁc paradigm best describe nursing phenomena?

References

Benner, P. (1984).From novice to expert: Excellence and power in clinical nursing practice. Menlo Park, CA: Addison Wesley.

Blendon, R. J., Benson, J. M., & Hero, J. O. (2014). Public trust in physicians U.S. medicine in international perspective. New England Journal of Medicine, 371(17), 15701572.

Brockman, J. (1995).The third culture. New York, NY: Simon & Schuster, 1996.

Frazier, K. (2009). Science under siege, defending science, exposing pseudoscience (p. 7). New York, NY: Prometheus.

Freese, J. (2001). Science under siege? Interest groups and the science wars.

Contemporary Sociology A Journal of Reviews,30(3), 266267.

Freire, P. (1973).Pedagogy of the oppressed. New York, NY: Continuum.

Gillis, C., Belluz, J., & Dehaas, J. (2010). Do you trust your doctor? Macleans.ca.

Retrieved from http://www.macleans.ca/news/canada/do-you-trust-your-doctor/.

Accessed on January 26, 2018.

10 Empirical Nursing: The Art of Evidence-based Care

(30)

Goldacre, B. (2008).Bad science. London: Fourth Estate.

Holmes, D., Murray, S. J., Perron, A., & Rail, G. (2006). Deconstructing the evidence-based discourse in health sciences: truth, power and fascism.

International Journal of Evidence-Based Health Care,4(3), 180186.

Marx, K., & Engels, F. (1965).The German Ideology ad Feurbach: An appendix in Ludwig Feuerbach and the end of classical German philosophy (1888) (C. Dutt, Trans.). London: Lawrence & Wishart.

Parse, R. R. (1992). Human becoming: Parse’s theory of nursing. Nursing Science Quarterly,5(1), 35.

Peirce, C. S. (1878). How to make our ideas clear. Retrieved fromhttp://www.marx- ists.org/reference/subject/philosophy/works/us/peirce.htm. Accessed on January 23, 2018

Phenix, P. (1962). The use of the disciplines as curriculum content.The Educational Forum,26(3), 273280.

Snow, C. P. (1993).The two cultures(2nd ed.). Cambridge: Cambridge University Press.

Steel Fisher, G. K., Blendon, R. J., & Lasala-Blanco, N. (2015). Ebola in the United States public reactions and implications. New England Journal of Medicine, 373(9), 789791.

Thorne, S. (2018). But is it“evidence”?Nursing Inquiry,25(1), e12229.

UK Science Council. (2009). What is science? Retrieved from http://www.science- council.org/content/what-science. Accessed on January 23, 2018.

Winters, J., & Ballou, K. A. (2004). The idea of nursing science.Journal of Advanced Nursing,45(5), 533535.

Science and NursingWhy Should I Care? 11

(31)

(32)

Chapter 2 The Rise of Empiricism

Those sciences are vain and full of error that are not born of experience, mother of all certainty.

Leonardo da Vinci (14521519)

An understanding of the foundations of modern scientiﬁc thought is a useful precursor to any exploration of the nature of contemporary nursing, and of EBP. Whilst this movement has really only developed its formal structures over the last 30 years, its philosophical roots date back much further. Whenever humans have encountered problems, humans have always sought solutions, and compared alternatives to strive for more effective solutions. This applies not only in nursing but also in all aspects of human life from farming to genetic engineering. Practitioners have based their practice on whatever evidence they had available and, in its absence, resorted to what is next best; intuitive, traditional, cultural and religious knowledge. Our approach to nursing is more scien- tiﬁc now than in the past, and so has more potential to further improve health outcomes in the future. This chapter explores some of the key elements in the development of empiricism, including inductive, deductive and abductive reasoning processes.

The Beginnings of Science

The exact origins of science are debatable but the termscientistis attributed to William Whewell (17941866). Previously, the term natural philosopher was commonly used to describe investigators of natural world, and this demarked a split of science and philosophy as separate approaches, to understanding knowledge with science denoting a focus on empirical knowledge.

Most modern historians would accept the origins of modern science arising from a variety of independent influences. In ancient India, at around 3000BCE, we have the first recorded evidence of attempts to standardise measurements with civilisations of the Indus valley. In the ancient East, Sumerian and Mesopotamian peoples are known to have started to record observations of the physical world with numerical data around 3500 BCE. Astronomical periods defined by the Mesopotamian people are still used today such as the solar year and lunar month. In most ancient cultures, intellectual thinkers were also priests, and the realm of astronomy and the cosmos was never too distant to those observing the world and struggling to associate it with a cosmological understanding (Teresi, 2003). Ancient Egyptians (315030^BCE) made many advances

(33)

in astronomy, mathematics and medicine. Early Babylonians (1800600 BCE) used mathematics with a base-60 system that contributed to our modern sense of time, the understanding of which seems to have been important to ancient peoples (Teresi, 2003). An Egyptian papyrus circa 1600BCEoutlines some records of traumatic injuries, illness, treatments (some surgical) and outcomes, demonstrat- ing some early principles in recording and analysing data (Allen, 2005).

Contrary to common belief, many early innovative thinkers and the foundational elements of science arose outside of the Western world.

Classical antiquity (800500 ^BCE) saw the rise of Greek philosophy with the work of Thales of Miletus (624546 BCE) who Bertrand Russell (18721970) described as the founder of Western philosophy. Thales’ideas exhibit some of the earliest attempts to explain natural phenomena without reference to deities, magic or mythology. Followed by Socrates (469399^BCE), Plato (424423^BCE) and Aristotle (384322 ^BCE), the early traditions of trying to explain the observed phenomenon by conjecture and hypothesis were developed. Socrates was reputed to be particularly concerned with ethics and had developed a systematic method of questioning (known as Socratic method) where a series of questions is asked to encourage detailed exploration and fundamental insights into a speciﬁc phenomenon.

One of Socrates’best-known arguments on the nature of knowledge is known as Meno’s paradox or the paradox of enquiry. In the Socratic dialogueMeno, written by his student Plato, a man called Meno asks Socrates ‘How could a man know that he has found which he searches, if he does not know which he searches?’Socrates answer was that if Meno’s assumptions were true, then men could neither search for which they know (for they would already have acquired it) nor would they be able to gather something new, since they would not be able to identify this thing to be what they were looking for to start with. In other words, how do we know when we have succeeded inﬁnding the right answer, if we don’t know what it is? Plato suggested an answer to this riddle in that, knowledge is forgotten memories and that learning consists of remembering those ideas. By this he proposed, a man could recognise the truth from the false- hood. However, the underlying premise that either you know what you’re looking for, or you don’t know what you’re looking for can be argued as a false dichotomy. It can also be argued that the pursuit of knowledge occurs in steps proceeding from limited initial knowledge of a phenomenon to increased knowledge, so the paradox is fallacious. However, the paradox embodies the notion that there could be an ultimate truth in the pursuit of knowledge towards which we are proceeding. This is an interesting point in scientiﬁc enquiry and one that is examined in more detail later in the book.

Plato was profoundly inﬂuenced by the teachings of Socrates and wrote copi- ously on the nature of reality and being (metaphysics). He argued, in his work Theaetetus, that knowledge could be distinguished from belief by its justiﬁcation (a position attributed to Socrates) and also discussed the nature of sophistry. In ancient Greece, sophists were intellectuals and private teachers who specialized in using argument and philosophy to earn money, usually by teaching wealthy statesmen’s children. Socrates himself had been described as a sophist, but Plato 14 Empirical Nursing: The Art of Evidence-based Care

(34)

differentiated them as charlatans who used rhetoric, ambiguities of language and underhand methods in order to deceive, rather than scholars interested in exploring the nature of knowledge and truth. Largely due to the inﬂuence of Plato and Aristotle, sophistry has become seen as distinct from philosophy, and today is regarded as specious and rhetorical argument, a characteristic commonly attributed to pseudoscience. Plato also argued truth could be discovered through dialectic, the resolution of disagreement through rational discussion, using propositions and counter-propositions, and the establishment of contradic- tions and inconsistencies. This remains a key principle in modern scientiﬁc argument.

Aristotle (Plato’s student) is another ancient Greek who had a profound inﬂu- ence on scientiﬁc thought. He is probably the best known of all the Greek philosophers and was an intellectual polymath. His views on the nature of the physical world and arts profoundly shaped medieval scholarship for several hundred years. He is credited with the earliest studies of formal logic and fundamental studies on the nature of matter, causality, motion, optics, biology and medicine.

Science in the Medieval World

Many of the works of Plato and Aristotle were translated into Arabic around 850 and after the fall of the Roman Empire (476) and subsequent decline of intellectual innovation in early medieval Europe (5001000), most of the development in scientific thought continued in the Islamic world. In this golden age of Islamic civilisation from 750 to 1258, Muslim culture spread across North Africa to France, from Persia to China, and south to India. The geographically central location of medieval Eurasia, in the midst of other cultures, was crucial in developing scientific practice at this time and the development of Arabic language and translations of the works of the Greek philosophers are certainly thought to have supported this process. In India, Brahmagupta (ca. 598668) a mathematician and astronomer developed the Hindu-Arabic numerical system pioneering the use of zero as a number circa 628. This is now used as the scientific standard throughout the world. Indeed, Indian mathematics continued to flourish on the continent until the British Empire invaded in 1858 (Corbin, 1993;

Teresi, 2003).

Another great Islamic thinker active in the second century was Alhazan, Ibn al-Haytham (ca. 9651040). He was a prime exponent of scientific thinking, making great contributions in the development of the scientific method and in the fields of physics, astronomy, mathematics and particularly optics. Another remarkable polymath, he led a very colourful life, at one time feigning madness to avoid the wrath of the Caliph when he failed to control theflooding of the Nile as he had predicted (Rāshid & Morelon, 1996). It has been suggested that Alhazen developed the experimental method of using controls to verify theoretical hypotheses (Gorini, 2003; Sabra, 1994), although this view is disputed as overstating his contribution by some academics (Smith, 1992). However, he The Rise of Empiricism 15

(35)

clearly developed the use of experimentation in his optical work, and also insisted upon the replication of results, and used the concept of Occam’s razor in his work (Corbin, 1993). Occam’s razor is a principle that suggests, when faced with competing hypotheses that are equal in other respects, selecting the one that makes the fewest new assumptions (i.e. is the simplest) is recommended.

This maxim for scientiﬁc enquiry is (somewhat contentiously) attributed to William of Ockham (12851349) but Al-Haytham clearly documents evidence of this idea in his Book of Optics in 1021 (Sabra, 1994). Another great Persian thinker, Abu Hamed Al-Ghazali, known as Algezel (1058111) described the idea of methodical doubt, proposing that we should question our beliefs and test them, an idea that was much later built upon by René Descartes (15961650).

Unfortunately, scientiﬁc advances in this part of the world declined by the end of the end of the Middle Ages, and the reasons for this remain an area of acute historical speculation. Invasions by the Mongols, crusaders and the destruction of Islamic libraries, as well as economic and political factors are thought to have all played a part (Al-Hassan, 2002).

In the West, after the collapse of the Roman Empire, Western Europe suf- fered significant depopulation with widespread plague and migration. The Black Death pandemic is estimated to have killed 3060% of Europe’s population in this period (Austin Alchon, 2003). Many Greek philosophical texts were lost and few remaining Latin translations existed. The common perception is that the development of scientific thinking in Europe stalled until the Italian renaissance of the fifteenth century, a thousand years later. This is commonly described as the period of the ‘dark ages’ dominated by religious dogma and superstition. Certainly, this was a time of religious dominance of thinking in Europe, characterised by the triumph of Christianity over the paganism of antiquity. However, during the twelfth century, the Byzantine civilisation of what was the Eastern Roman Empire (based in the capital of Constantinople, now Istanbul) experienced a period of rapid intellectual and scientific development.

Some historians refer to this period as the Twelfth Century Renaissance, where increased contact with the Islamic cultures to the East allowed Europeans to translate the works of antiquity that were otherwise lost to European scholars of this period, and to also become inﬂuenced by other Islamic scientiﬁc texts (Huff, 2003).

Examples of important scientific advances are such innovations as the invention of eyeglasses in Italy in 1286, and the introduction of Hindu-Arabic numer- als to Europe by Leonardo of Pisa (11701202). The first recognisable universities were also established during this time in Italy, France and England, and access to the translated texts allowed them to aid propagation of new ideas and eventually start a new infrastructure for scientific communities. The English Franciscan friar Roger Bacon (12141294) studied at the newly established Oxford University and advocated for the use of the inductive reasoning processes to acquire knowledge and that inductively derived conclusions (propositions based on experience and observation; see Table 1) should then be submitted to experimental testing (Clegg, 2003). This remains a fundamental idea in modern science.

(36)

Eventually, the loss of the Byzantine lands (in the East to the Turks and in the West to Bulgaria) resulted in the fall of Byzantium in 1453. However, the resulting migration of Byzantine scholars West helped to spark the laterItalian Renaissance, which was to be a time of huge change and development for the arts and for science (Huff, 2003).

The Renaissance and Scienti ﬁ c Revolution

Generally, the consensus is that the Italian Renaissance commenced in Florence in Tuscany in the fourteenth century (kick-started by the many works commis- sioned by the immensely powerful Medici family), spread to the rest of Europe by the sixteenth century and lasted until the seventeenth century. The Renaissance represented a great cultural movement with a new focus on literary and historical texts and exploration facilitated by the use of the magnetic com- pass (including the discovery of the New World by the European Christopher Columbus in 1492). The invention of the printing press in 1436 also had a huge impact on the dissemination of ideas, and democratised learning. The new Table 1: Inductive, Deductive and Abductive Reasoning.

Characteristics Ability to Guarantee a Sound Conclusion

Fitness for Purpose

Inductive reasoning

Begins with

observations that are speciﬁc and limited in scope and proceeds to a generalised

conclusion

Provides a conclusion that is likely, but not certain

Identiﬁes patterns, establishes general trends for further exploration. Often used in qualitative exploratory research Abductive

reasoning

Begins with an incomplete set of observations and proceeds to the likeliest possible explanation

Relies on

information at hand, which often is incomplete so provides a conclusion that is likely, but not certain

Useful for creative thinking and hypothesis generation. Also, useful for explaining the acceptability of treatments and patient preferences Deductive

reasoning

Starts with the assertion of some general rule and proceeds from there to deduce a speciﬁc conclusion

Excellent, if premises sound and process correctly applied, then it provides a sound conclusion

Validation of speciﬁc hypotheses. Often used in quantitative research and comparative trials The Rise of Empiricism 17

(37)

Renaissance scholars studied the newly available classical sources enshrining both the old Aristolean and Ptolemaic views of the universe.

Renaissance scholars were generally more interested in culture and art, rather than the Greek and Arabic works of natural sciences, philosophy and mathematics, and so initially, the development of scientific thinking was rather stunted until the mid-sixteenth century. Ideas such as the classical elements of earth, water, fire, air and aether making up the physical world and a geocentric universe persisted during this time. Art and scientific perspectives were also very much intertwined in the early Renaissance. Ideas of humanist theology developed, embodying the ideals of humanity in physical, psychological and spiritual terms.

The best-known exponent of Renaissance ideals is probably the most famous polymath of all time, Leonardo da Vinci (14521519 ^CE). Leonardo da Vinci made incredibly accurate observational drawings of anatomy and nature using systematic medical dissection, but also devised controlled experiments in water flow, made systematic study of movement and aerodynamics and devised basic empirical research methods that led to his description by some as the‘father of modern science’ (Capra, 2007). His view of the world was more logical than mysterious, and the empirical methods he employed (such as repeated observation, meticulous note taking and use of hypothesising and experimentation) were very unusual for his time. He is best renowned as an artist, and particularly as the painter of the famous Mona Lisa. Although Leonardo made important discoveries in anatomy and otherfields, he did not publish hisfindings and many of his discoveries, such as his anatomical sketches, only came to light many years later, so not directly influencing the progress of science in his lifetime.

Leonardo’s Vitruvian Man probably best exemplifies the blend of art and science of the Renaissance period providing the perfect example of Leonardo’s keen interest in accurate proportion, balance and the relationship of man to nature. The drawing was based on the ideas of ideal human proportions geomet- rically described by the ancient Roman architect Vitruvius (70BCE15^CE) in his bookDe Architecture. This is believed to be the only contemporary source on classical architecture to have survived in its entirety and was one of the classical texts now available to Leonardo and his contemporaries. This fusion of creativity, art and science and his use of both inductive and deductive processes in scientific rationale were themes that would later become more important in the development of modern scientific thinking.

The great fusion of the arts and sciences developed with a slow shift away from the control of knowledge by the Roman Catholic Church, representing revolution in thinking, and challenge to authority and dogma. The practice of using new empirically based ideas to challenge established wisdom has become an established aspect of sceptical scientiﬁc enquiry today.

Leonardo da Vinci wrote, ‘anyone who in discussion relies upon authority uses, not his understanding, but rather his memory’ (Nuland, 2005). Scientiﬁc scepticism of the status quo and authority is an important aspect of modern EBP. In modern science, authority isn’t really worth a jot, and concepts are presented to the world for open consideration as to their merits, for peer review and 18 Empirical Nursing: The Art of Evidence-based Care

(38)

challenge. The key principle being that, in this way, ideas will become reﬁned, and bad ones rejected. This remains aﬁrm part of academic training, with PhD candidates still being required to defend their theses in robust discussion with their peers today.

The peer review of scientiﬁc studies prior to publication is another modern embodiment of this principle. Interestingly, modern medicine is often criticised as being authoritarian, conspiratorial, all-controlling and closed to any alternative perspectives, prompting Ben Goldacre, a well-known UK physician to ask

‘Is mainstream medicine evil?’ (Goldacre, 2008). The argument of medical

authority inﬂuencing healthcare through political inﬂuence, and legislative control maintaining the hegemony can certainly be made. However, in terms of openness to alternative therapeutic interventions, the adoption of EBP in medicine would seem to support challenges to established wisdom and presents an opportunity for change that nursing has yet to fully embrace and take advan- tage of.

The Renaissance was also a time of great religious upheaval and division resulting in the reformation and breakup of the Roman Catholic Church.

Acceptance of new ideas varied amongst church leaders and there wasfierce resis- tance by many. Examples of this include the initial rejection of Gallileo Galliei’s (1564–1642 CE) arguments against a geocentric universe by the church, and Girolamo Savonarola’s (14521498 CE) bonfire of the vanities, where the Dominican friar burned books and artworks deemed offensive to pious religious thought in Florence in 1497. It is also argued by contemporary historians that many negative cultural aspects actually got far worse in this period, including religious persecution, witch hunts, censorship, wars and papal corruption (Martines, 2006). In 1543, Copernicus’sOn the Revolutions of the Heavenly Sphereswas published, and Andreas Vesalius’s (15141564^CE)On the Fabric of the Human Body, a text documenting the role of dissection, observation and a mechanistic view of human anatomy. These two empirical works openly challenged previously established doctrine, and, together with the works of Leonardo da Vinci, and later Francis Bacon (15611626), established what became known as the scientific revolution and furthered the development of the scientific method.

The Age of Enlightenment

The end of the Renaissance set the stage for another era of profound scientific advances in seventeenth and eighteenth century Europe, known as theAge of Enlightenment (or the Age of Reason). This set in motion the development of modern science (Lindberg, 2007). The technologies developed during this time supported the industrial revolution, marking a major turning point in human history. The income and general living standards of the majority of ordinary people began to undergo sustained growth for the first time in history (Lucas, 2002). The result of this was an age characterised by a cultural movement in Europe fostering new ways of thinking and witnessed an outpouring of human knowledge in almost everyfield.

The Rise of Empiricism 19

(39)

Enlightenment thinkers such as René Descartes (15961650), Benedict de Spinoza (16321677), Gottfried Leibniz (16461715), John Locke (16321704), George Berkley (16851753), Voltaire (16941778), David Hume (17111776) and Immanuel Kant (17241804) all examined the rational basis of beliefs and, in the process, mainly rejected the authority of church and state. Kant expressed the maxim of the Enlightenment very well with ‘aude sapere’ (dare to think).

Scientiﬁc academies and societies developed as the creators of new scientiﬁc knowledge alongside the universities. After 1700, a large number of these learned societies were founded in Europe such as the Royal Society of London (1662) and the Académie Royale des Sciences in Paris (1666). The era also brought the popularisation of science forward with better social conditions and the introduction of the printing press, although women were generally excluded from the movement and not allowed membership of the academies or universities (Porter, 2003).

During the Enlightenment, Johannes Keppler (15711630) developed and published new laws of planetary motion), and Isaac Newton (16421727) laid the foundations of classical mechanics with his book Philosophae Naturalis Principia Mathematica in 1687, removing the last doubts about heliocentrism.

Newton was probably the most famous thinker to come out of this period, and in his monograph Philosophiae Principia Mathematica, he set out the foundations of classical mechanics describing gravity and motion that lasted for 200 years.

Mathematical Probability

The discipline of mathematical probability got started at this time with the work of Pierre de Fermat (16071665), Blaise Pascal (16231662), Christian Huygens (16291695), Jacob Bernoulli (16541705) and later Pierre Laplace (17491827) and Thomas Bayes (17021761). The ideas they presented were seized on by a variety of scientific fields including medicine and have had a profound influence on modern science with very accurate methods developed to predict the likelihood of an event occurring (Salsburg, 2001).

Early scientists like Newton wanted to ﬁnd a more objective way to judge when a hypothesis was considered conﬁrmed, and mathematical probability provided them with the tools to do just that. In classical probability theory arising from the work of de Fermat, Pascal, Huygens, Bernoulli and Laplace, instead of dealing with only one possible reality of how a process might develop under time, the probability of an event occurring is expressed as stochastic (random) process where there is some indeterminacy described by a probability distribution. These distributions use a ratio of the number of possible occurrences to the total possible outcomes. A 100% certain event (the sun will rise tomorrow) would get the value of one, an event we are sure will never happen (possibly a surgeon asking for a physician’s or nurse’s advice) would be ascribed the value of zero. A single roll of a normal die would give a probability of 1/6, as there are six possible outcomes and only one occurrence.