Editorial: ‘Evidence-based healthcare – a lot of bull?’

In their book Zen Flesh, Zen Bones: ACollection of Zen and Pre-Zen Writings,Reps and Senzaki (1998) draw on thephilosophies, meditations and paintingsof the ancient Chinese philosopher andBuddhist teacher ‘Kakuan’ and his useof the metaphor of the bull to illustratethe search for truth in action. Throughthe metaphor of 10 different bulls,Kakuan captures the challenges in lifeof trying to establish ‘the truth’ fromwhich to live our lives. In thinking aboutthe way that evidence-based healthcarehas become a dominant focus of muchpolicy strategy, research, education andpractice, Kakuan’s bulls provide a meta-phor that should help us challenge thedominance of empirical evidence in ourthinking about evidence-based practiceand clinical effectiveness.

In the pasture of this world, I endlessly push

aside the tall grasses in search of the bull.

Following unnamed rivers, lost upon the

interpenetrating paths of distant mountains,

my strength failing and my vitality exhausted,

I cannot find the bull. I only hear the locusts

chirring through the forest at night (Reps &

Senzaki, 1998).

This metaphor of the first bull inKakuan’s series of 10 illustrates howmuch effort and resource has beeninjected into finding the ‘right’ evidence(the bull) upon which to base practiceand in doing so we have tended to looktowards external sources of evidence(pushing aside the tall grasses) in searchfor the answer to specific problems andissues. The evidence-based healthcaremovement has placed great store onhierarchies of evidence, systematicreviews and the production of ‘hard’evidence to justify our practice. Centresfor innovation have been established inmany universities to co-ordinate andmanage the production, disseminationand translation of evidence into practice.However, the challenges associated withgetting evidence into practice do not

appear to get any less and the barriers toevidence use appear to remain as great asthey ever have been despite a plethora ofresearch and development. A variety ofstrategies have been explored and con-tinue to be explored with new methods,methodologies and theories about know-ledge translation being developed all thetime. Despite this growth in knowledgetranslation, the ‘magic bullet’ is as elu-sive as ever. Whilst we have an increas-ing sense of knowledge translationstrategies that are more effective thanothers, the route to getting there remainsunclear and uncharted like the locustschirring through the forests at night. Butlike the bull, what need is there to searchif we truly engage with the study ofpractice? In the nine bulls that follow,Kakuan argues that real truth is foundfrom within and that starting fromwithin enables us to gradually integratethe different forms of knowing in orderto find ‘peace’, i.e. truth. And so it is withgerontological nursing practice. Work-ing with older people requires us toconsider the person first and from thatperspective to build a knowledge baseupon which to base practice. Knowingself is key to being person-centred. Muchof the knowledge about self and the ‘self-in-relation’ with others is embedded inpractice in the relationship between dif-ferent persons in different caring con-texts. Person-centred caring requires anengagement that is not derived fromexternal sources of knowledge alone, butinstead is based on an integrated form ofknowing that enables effective engage-ment between persons. More con-temporary thinking in evidence-basedhealthcare recognizes that the contextof practice is significant to the effective-ness of practice outcomes and the faci-litation of effective engagementstrategies enables meaningful relation-ships to develop with older people.Whilst external evidence is importantto the effectiveness of particular techni-cal outcomes, effective practice in ger-ontological nursing cannot be measured

by technical evidence alone. Hardy et al.(2006) recently identified the complexityof clinical expertise and the challengesassociated with evaluating outcomesfrom expert practice. The complexity ofoutcome measurement with older peoplewas further illustrated in the ‘PracticeDevelopment Papers’ of the Interna-tional Journal of Older People Nursing(Hallberg & Kristensson, 2004; Meyer& Sturdy, 2004) with the challengeposed for new and innovative strategiesto be developed in order to capture thediversity and creativity of practice.

The papers in this edition of theInternational Journal of Older PeopleNursing have a dominant focus onevidence-based practice and differingapproaches to effectiveness. They drawon a diverse range of studies that rangefrom attempts to measure the researchuse among nurses who work with olderpeople, to studies that explore differentaspects of clinical effectiveness, throughto new ways of thinking in and aboutnursing practice with older people.These papers complement the ‘practicedevelopment’ section of the journal,which focuses on ‘risk’ with olderpeople – something that challengesmany aspects of policy, strategy andpractice and which some forms of out-come measurement fail to take accountof. Our need to be eclectic in our view ofresearch use, knowledge translation andclinical effectiveness is paramount andsomething that the International Journalof Older People Nursing is committedto, for as Kakuan suggests:

Along the riverbank under the trees, I dis-

cover footprints! Even under the fragrant

grass I see his prints. Deep in remote moun-

tains they are found. These traces no more

can be hidden than one’s nose, looking

heavenward (Reps & Senzaki, 1998).

The evidence we need for practice isall about us. To continue to look forexternal direction will result in failure to

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follow the footprints created in andthrough practice that directs us towardsperson-centred effectiveness. We need tocontinue to search for effectiveness, butwe need to do so through criticalengagement in meaningful person-centred relationships.

Brendan McCormackJan ReedEditors

References

Hallberg I. & Kristensson J. (2004) Preven-

tive home care of frail older people: areview of recent case management studies.

International Journal of Older PeopleNursing 13, 112–120.

Hardy S., Titchen A., Manley K. & McCor-mack B. (2006) Re-defining nursing

expertise in the United Kingdom. NursingScience Quarterly 19, 260–264.

Meyer J. & Sturdy D. (2004) Exploring the

future of gerontological nursing outcomes.International Journal of Older PeopleNursing 13, 128–134.

Reps P. & Senzaki N. (1998) Zen Flesh, ZenBones: A Collection of Zen and Pre-ZenWritings. Shambhala, Boston.

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Editorial