By Victoria Min-Yi Wang and Brian Baigrie.
The idea for our paper, Caring as the Unacknowledged Matrix of Evidence-Based Nursing, germinated in a philosophy of medicine graduate class that Brian was teaching and Victoria was attending. As a group, we discussed what counts as evidence in medicine, how values do and should enter into clinical decision-making, as well as the merits and drawbacks of evidence-based medicine. Evidence-based medicine is a prevalent movement within medicine that prioritises evidence collected from randomised controlled trials and the information aggregated from such trials over other forms of evidence, including data from observational studies and the personal experiences of healthcare practitioners.
When philosophers of science and medicine have criticised evidence-based medicine it has usually been because of methodological problems related to this prioritisation of randomised controlled trials. However, as we were debating these issues it struck me that two things were missing from the literature we were reading: first, a certain “human element” to the critique (rather than a purely methodological critique); second, constructive work that could connect the best elements of evidence-based practice with the caring aspects of medicine and nursing. Wanting to address this gap, and influenced by a parallel graduate class in feminist philosophy, I began by asking how feminist care-based approaches could critique or supplement the seven-step instruction manual laid out in an influential handbook on evidence-based nursing (EBN).
What we ended up with in our paper is the idea that caring attitudes and practices help fill in some of the gaps left open by this seven-step guide to EBN. In particular, we draw on the work of feminist philosopher Vrinda Dalmiya to broaden the concept of care: we start with care as an ethical concept that turns out to be important for knowledge production. Dalmiya distinguishes two types of care-knowing: the first is one in which knowledge of another person in a caring relationship, such as between nurse and patient, is increased through the caring process itself, and in turn the more knowledge a nurse has about a patient, the better their care can be. The second type of care-knowing concerns knowledge more broadly and suggests that nursing knowledge can be acquired in a care-full manner when nurses care about their profession. This broader knowledge might include wanting to understand and incorporate evidence-based practices into existing nursing practices.
This interweaving of EBN with care-based approaches will seem abstract. To illustrate what we mean let’s look at an example. The EBN framework insists that asking the right questions in a clinical context is important for gathering the right kind of evidence. In the EBN handbook we analyse, the authors ask “if your mother were diagnosed with Alzheimer’s disease, would you want her healthcare provider to give you information about how other family caregivers of patients with this disease have coped with the illness, based on evidence from well-designed studies”? In response we suggest that it might be the case that some family caregivers will want such information, but that a nurse will be able to find the right response to such a situation only by engaging in care-knowing work. For example, by getting to know families affected by an Alzheimer’s diagnosis, the nurse might suggest watching movies such as Still Alice or Supernova, which present fictional accounts of how people cope with cognitive decline and illness in their loved ones, to one particular family, while suggesting to get help from a social worker to another family. This is one example of how explicitly incorporating care into the seven steps of EBN can supplement or even strengthen the evidence-based approach.
However, we want to make clear in our blog post – and we think it’s great that the Journal of Medical Ethics provides this informal venue to do this – that neither Brian nor I are healthcare practitioners and we lack the hands-on experience of performing care work in a clinical setting. Although we draw on real-world examples and other people’s practice-informed writing, the discussion in our paper remains at the theoretical level. We would therefore particularly welcome feedback and responses from healthcare professionals and nurses. Are the care-knowing practices we are describing here already a given in clinical practice, even where EBN is the dominant paradigm? Do the two ways of care-knowing seem familiar from clinical encounters and the nursing profession? Are there ways in which the concepts of care-knowing can be refined by drawing on clinical experience? Are there other (clinical) examples that could move this discussion further? Finally, are there other gaps within the EBN framework that could be addressed with resources from care theory?
Authors: Victoria Min-Yi Wang and Brian Baigrie
Affiliations: Department of Philosophy (VW) and Institute for the History & Philosophy of Science & Technology (BB), both at the University of Toronto.
Competing interests: None declared.