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Liberating clinical effectiveness: A model for consideration

Allyson Lipp
Principal Lecturer, RCBC Post-Doctoral Fellow, Faculty of Health, Sport and Medicine, University of Glamorgan, Pontypridd, Wales, United Kingdom

Abstract

This paper explores Habermas' knowledge constitutive interests as a basis for clinical effectiveness. Clinical effectiveness and evidence based practice are clarified and Habermas interpretation of critical theory is introduced as an instrument which could arguably fulfil the needs of both concepts. The knowledge constitutive interests have the capacity to encompass science and evidence based practice via technical knowledge, the practical interests via interpretive knowledge and the freedom to change practice via emancipatory knowledge. This gives an opportunity for technical science and interpretive knowledge to facilitate the liberation of nurses via clinical effectiveness. The paper culminates in the presentation of a visual model to articulate this proposal.

Keywords

clinical effectiveness, Habermas, emancipation

Article Text

This paper will commence with an explanation of clinical effectiveness how it should be distinguished from, and incorporate, evidence based practice. It will then be argued that Habermas' knowledge constitutive interests comprise a potentially useful model, which could emancipate clinical effectiveness.

Firstly, clinical effectiveness and evidence based practice will be defined and differentiated. Clinical effectiveness has been central to the debate surrounding health care in the last few years. Both evidence based practice and clinical effectiveness have developed and have extended their repertoires from being straightforward, virtually theoretical concepts towards being pragmatic, functional, relevant models to assist practitioners in the health care environment in becoming clinically effective. Despite this much of the current literature lacks a clear distinction and tends to merge the two concepts which risks doing them both an injustice (Adams, 2000; Dawson, 2001; Jennings and Loan, 2001). The confounding of clinical effectiveness and evidence based practice is at best unhelpful and at worst misleading thus clarification of both concepts will follow to avoid this misconception.

Winyard (1995) provides a useful definition encapsulating the multiple elements of clinical effectiveness.

'A co-ordinated approach which brings together research evidence, clinical guidelines, clinical audit and outcome assessment is essential if we are to ensure that patients have access to health care of proven quality and that the greatest benefit can be realised from available resources' (Winyard, 1995: 1)

Cox and Reyes-Hughes (2001) view clinical effectiveness similarly in that they understand it to encompass evidence based practice, research into outcomes, clinical audit and clinical governance. They also claim this approach will reduce the overall cost of unnecessary interventions (Cox and Reyes-Hughes, 2001).

The NHS Executive definition of clinical effectiveness is also one commonly cited as

'The extent to which specific clinical interventions when deployed in the field for a particular patient or population do what they are intended to do, that is, maintain and improve health and secure the greatest possible health gain from the available resources' (NHS Executive, 1996a: 6)

In contrast to clinical effectiveness evidence based medicine was initially used exclusively by doctors to encourage legitimate questioning of practice and emanates from McMaster University in Canada. Sackett (one of its orginators) and colleagues defined it as

'the conscientious, explicit, and judicious use of current best evidence in making decisions about the care of individual patients' (Sackett et al., 1996: 71)

However more inclusive terms such as evidence based health care and evidence based practice which reflect moves towards more interdisciplinary working tend to be favoured currently (Dawes et al., 1999).

Evidence based practice comprises five steps, which involve focussing on an issue and developing a rigorously formed question in order to be able to search the evidence effectively (step 1). Once the search is complete and the relevant evidence has been obtained it can be placed into a hierarchy (Step 2). The hierarchy ranks evidence in order of scientific merit with systematic reviews and randomised controlled trials being more highly valued than government reports and expert opinion (Gray, 1997). Even with a hierarchy, no evidence is faultless and so the next step to ensure EBP is to critically appraise the evidence according to its classification (Step 3). If the evidence is found to be robust it can then be applied to practice if appropriate (Step 4). Finally, evaluation of the adopted practice will ascertain whether it improves practice and completes the steps of EBP (Step 5).

In order for evidence based practice to maintain its scientific stance it is proposed that it is embedded into clinical effectiveness. The less scientific forms of evidence such as audit, patient outcome measures and qualitative information would be applied to practice as part of the local assessment of clinical effectiveness. This would allow both concepts to develop remaining relatively pure, whilst benefiting from the close association with each other. This proposition has been discussed in more detail elsewhere (Lipp, 2002). As a result of embedding EBP into clinical effectiveness a model was developed illustrating how clinical effectiveness and evidence based practice are positioned within Habermas' knowledge constitutive interests (Figure 2). The two tails of the arrow represent this with the left tail signifying technical scientific knowledge and the right tail demonstrating hermeneutic sciences. Towards the arrow head the two tails merge to include the issues which intersect both interests.

Having clarified the concept of clinical effectiveness and situated evidence based practice within it, Habermas' knowledge constitutive interests will now be considered in order to explain how they can be employed to emancipate clinical effectiveness.

Habermas, critical theory and clinical effectiveness

Critical theory has a wish to find a new world through critiquing the old (Theunissen, 1999) and on this level appears to have a goal in common with clinical effectiveness.

This endeavour to evaluate a potential solution of positioning clinical effectiveness into critical theory is not without risks. According to Lechte (1994), the risks commence with Habermas' outdated view of science. Nevertheless his classic work 'Knowledge and Human Interests' (1972) with its three attendant 'knowledge constitutive interests' has gained a place in many nursing theoretical papers and Habermas is the critical theorist to which many nursing authors subscribe. His theory has been advocated as a framework by multiple nursing authors (Kendall, 1997; Ghaye et al., 2000; Kim, 1999; Taylor, 2000). Wilson-Thomas (1995) recommends critical theory as a means to radically reflect upon the links between theory, research and practice in order to empower nurses. Berragan (1998) also recognises the need for technical, interpretive and emancipatory perspectives to free nursing from being an oppressed group (Berragan, 1998).

It is Habermas' knowledge constitutive interests that provides the underpinning framework for this paper rather than his more recent developments and the term critical theory when used will be limited to these concepts. Habermas admits that his work requires further explication and completion and that most of the theses raised in his early work have been reformulated or revised (McCarthy, 1978). This creates one of the major challenges of using Habermas as a basis for clinical effectiveness in that he has spent his life developing his own brand of critical theory. A critique of his early work would fail to appreciate that he has since rectified any deficiencies. Similarly to critique his work via other critical theorists would undervalue the differences between the various schools of critical theory. His influence upon 20th (and now 21st) century thinking should not be underestimated as he tackles both great and small theories. Unfortunately, according to one of his enthusiasts, Habermas writes in a style that deters potential audiences (Outhwaite, 1994).

Habermas' three knowledge constitutive interests are technical, practical (interpretive) and emancipatory. Habermas suggests that they are transcendental and presupposed by any cognitive act (Carr and Kemmis, 1986). This is a rather tenuous footing upon which to base a theory and they have been criticised for lacking validity and utility (Held, 1980). Theunissen (1999) goes further in accusing them of falling prey to the very ideology that Habermas eschews. Notwithstanding this flaw as inherent I would assert their utility in providing a pragmatic framework for clinical effectiveness. A schematic representation of the knowledge constitutive interests from Carr and Kemmis (1986) is cited below to demonstrate the association between the interests and the knowledge of critical theory. (See Figure 1.)

To examine whether critical theory would be an appropriate domicile for clinical effectiveness the three knowledge constitutive interests and their potential relationship to clinical effectiveness will now be examined in turn.

Technical empirical knowledge

Habermas is a modernist and as such he argues against attempts to dismiss the legacy of Western rationality (Bernstein, 1985). Habermas advocates the use of empirical science, but only as one form of knowledge. Some professions arose out of adherence to technical empirical knowledge, such as medicine, whereas others, including nursing, developed from the professional realms of action that requires practical wisdom (McCarthy, 1978). The difference in origins and philosophies of these two professions has tended to echo the respective adoption of evidence based medicine (practice) and clinical effectiveness.

Evidence based practice epitomises the dominance of technical science in health care. This dominance places EBP at risk of being 'scientistic'. Habermas coined the term as 'scientistic' as science believing in its own supreme power (Carr and Kemmis, 1986). Because of its basis in the dominant technical science the political strength of EBP has gathered more subscribers resulting in the exclusion of other sources of knowledge. Therefore, its influence should not be underestimated (Higgs and Jones, 2000). This could have a detrimental effect on the allocation of resources. For example, if they are allocated based on technical knowledge a lack of evidence could result in withdrawing resources from a vital area of health care. Areas with the emphasis upon the practical and social are vulnerable. For example an impasse between EBP and mental health is recognised (Lines, 2001) with a resultant lack of value being attached to health care in this area. This deficit risks oppressing nursing by subscribing solely to technical knowledge via the scientism of EBP.

The mechanical and sole adherence to technical science is gradually receding with nurses becoming analytical and reasoned in their examination of EBP (McKenna, 2000; Rolfe, 1999; Wallace et al., 1997). Many authors concur that nursing should not be restricted to technical empirical knowledge, but they do not necessarily provide a solution to this flaw (Mulhall, 1998; Mitchell, 1999). Moreover, Fish and Coles (1998) claim that practitioners even tend to shy away from technical knowledge as it fails to answer the questions that they pose. Although nurses may be in awe of EBP and reticent of embracing it Habermas would disagree with devaluing technical science and argues that it has a central role to play in knowledge acquisition (Carr and Kemmis, 1986).

The need for other sources of knowledge in addition to technical science has been the subject of extensive debates in the nursing press over decades (Appleton, 1993) (Peplau, 1988). Hicks argues that the complexities of nursing are all but ignored by adhering solely to technical science, particularly randomised controlled trials (RCT) (Hicks, 1998). In a bid to placate those appealing for augmentation of technical science lip service has often been paid to interpretive knowledge. For example, Sackett's later definition of EBP claims to integrate the softer approach of gaining knowledge via the clinician's experience. However the subsequent text concentrates upon the harder method of RCTs as the 'gold standard' advising avoidance of non-experimental approaches to prevent bias (Sackett et al., 2000). An insightful comment made by Mitchell (1999) throws practical interpretive knowledge into relief. She states that individuals make decisions to accept scientific evidence based on their own world view, thus making the use of practical interpretive knowledge inevitable. Technical science would not only benefit from another knowledge constitutive interest, but actually requires it to avoid the scientism feared by Habermas (Carr and Kemmis, 1986). Introducing another knowledge constitutive interest would only be advantageous if they are both compatible.

The theory–practice gap, a commonly discussed phenomenon in nursing (Upton, 1999), has been reframed as the theory–theory gap between technical and practical knowledge as Fish and Coles argue that they lack compatibility (Fish and Coles, 1998). The argument for combining technical expertise with practical wisdom outweighs this tension and is now being recognised by those within EBP (Bandolier, 2002). Just as the shibboleth of technical science is the truth, so the shibboleth of practical knowledge is practical judgement (Carr and Kemmis, 1986).

Practical interpretive knowledge

'We must avoid making what is measurable important and find ways to make the important measurable' (Bandolier, 2002: 2)

This maxim encapsulates the realisation that although evidence based scientific knowledge is relatively straightforward to capture, there is a need to find ways to measure the lived experience. Technical knowledge is developed theoretically and is applied to practice. In practical knowledge, learning arises from practice. Therefore, practice becomes the starting point for understanding, which according to van Manen (1990) fulfils a fundamental human need to develop understanding from experience.

Mezirow who bases his model of learning on Habermas' critical theory claims that we understand through searching for themes and metaphors in which to fit unfamiliar experiences into a meaning perspective so that interpretation becomes possible (Mezirow, 1981). I would argue that we would also benefit from examining the familiar as it is this practice which is likely to be least clinically effective.

Language is embedded in practical knowledge and is central to understanding and interpreting the world (Byrne, 2001). Language may be expressed as text, story telling, and narration and is interpreted by Habermas via the two essential devices of phenomenology and hermeneutics. Hermeneutics has a long history that stems from a technical method of interpreting biblical texts, literature and works of art (Carr and Kemmis, 1986). It has developed to become an inductive process based on the interpretation of language associated with life experience and individual meaning (Habermas, 1972). Phenomenology shares the inductive approach to building knowledge with hermeneutics and proposes that a phenomenon can be described instead of being explained. It focuses upon the things themselves rather than any causal relationships (Sadala and Adorno, 2002).

Interpretive knowledge involves appreciating the lived experience. The lifeworld is the taken-for-granted everyday life of social activity. The term lived experience is used by Taylor to address this phenomenon. She states that it is knowing what it is like to live life in a particular time, place and set of circumstances. Lived experiences accumulate and gather interpretive significance, as they are remembered (Taylor, 1998).

Interpretive knowledge attempts to grasp reality or understand (verstehen) in order to reveal meanings. This is undertaken by systematically articulating or translating certain actions or situations via phenomenology and hermeneutics amongst other techniques. According to Held (1980), all interpretation should be given the status of a hypothesis. This systematic approach adopts scientific principles, but avoids the charge of being a 'reality-in-itself' (Habermas, 1972). Hence, interpretation elucidates the link between knowledge and the constitutive interests from the life world.

A major tenet of clinical effectiveness is that it is centred upon real health care settings. It therefore cannot be limited to scientific explanations, but also requires interpretive practical knowledge (Carr and Kemmis, 1986; Upton, 1999). I would argue for the use of interpretive methods of knowledge acquisition to lessen the divide between EBP and clinical effectiveness. This response echoes the assertion that qualitative methods can help bridge the gap between scientific evidence and clinical practice (Green and Britten, 1998). Greenhalgh's narrative approach is an example of a functional bridge with technical meeting practical (Greenhalgh, 1999).

Just as technical science has flaws there are concerns regarding practical knowledge. For example, there is a risk that actions could be reinterpreted for its own purposes, to reinforce its legitimacy and justify its existence (Carr and Kemmis, 1986).

Validating knowledge arising from practice is also demanding, as it is unable to provide objective standards for verifying or refuting theory (Carr and Kemmis, 1986). This is because it involves a judgement and any judgement is confined to our own meaning perspective (Mezirow, 1981). Mezirow terms this process the hermeneutic circle where the practitioner moves back and forth between events and the phenomenon hypothesizing and falsifying the hypotheses to generate knowledge. One could assert that this is a strength as the practitioner increases the rigour of the knowledge. Equally, it could be classed as a weakness because if the knowledge remains tacit validation is not possible. Alternatively, deficient judgement or validation by another could lead to misinterpretation (Carr and Kemmis, 1986). In a bid to lessen this risk Kendall asserts that validity of practical knowledge can be tested via several means including triangulation, construct validity, face validity and catalytic validity which measures its association with emancipation (Kendall, 1997).

McCarthy (1978) claims that objective knowledge produced by empirical enquiry is not possible without practical knowledge of intersubjective understanding The uniting of the two knowledge constitutive interests prepares the way for the third interest of emancipation.

Emancipatory knowledge

The third knowledge constitutive interest of emancipatory knowledge serves to remove the power structures that maintain oppression (Rolfe et al., 2001). It could therefore be argued to provide a useful lever to aid the emancipation of clinical effectiveness. Emancipation involves the development of self knowledge in order to be able to expose power dynamics and reveal hitherto concealed hegemony. The new found insight allows scrutiny of and ultimately control over forces which are dominating. The process is aimed at removing false consciousness in order to achieve freedom from constraints such as oppressive social structures and ideologies (Wilson-Thomas, 1995).

Oppression is associated with disempowerment and it implies keeping in subservience or dominating. In the literature, oppressed groups include women and those in the caring professions, particularly nurses (Fulton, 1997; Kuokkonen and Leino-Kilpi, 2000). In a similar way to women, Taylor states that it is the 'outerfocused' nature of health care that leads to oppression. By focusing on the needs of others, the needs of the health care professionals are not usually in focus thus making them a target for domination (Taylor, 2001a). Nurses in particular are said to have a history of oppression and continue to be criticised for their silence despite the burgeoning numbers of over half a million in the United Kingdom (Ghaye et al., 2000). However, Napier-Skillings asserts that 'there is no hierarchy of oppression and that to be oppressed is to be other than' (1992: 167).

The oppressed learn to imitate the oppressors such as taking similar titles, using the same language and performing similar rituals. It is understandable that the oppressed wish to emulate their oppressors because reality is defined by them (Napier-Skillings, 1992). Through this process, the oppressed learn to hate themselves. This leads to a cycle of characteristics such as manipulation, self-depreciation and low self-esteem, all of which are endemic in nursing (Napier-Skillings, 1992; Fulton, 1997; Freire and Macedo, 2001).

Emancipatory interests are not grounded in power, but are directed against power and unjustified domination (Outhwaite, 1994). Terms associated with emancipation such as domination, oppression, hegemony and ideology are all concepts that nurses and patients can identify with. This could be the incentive for clinical effectiveness to take on the mantel of Habermas' knowledge constitutive interests in order to liberate those involved in delivering and receiving health care.

A major purpose of emancipation is to eradicate ideology. Ideology is a false consciousness where the understanding of a group is false, or internally inconsistent (Fay, 1987). Taylor (2000) warns that false consciousness could prevent a critique of circumstances. She cites oppressive daily routines remaining unquestioned because they are unnoticed. Although a major aim of EBP was to question practice it has now become so firmly embedded within health care that it in turn risks becoming an ideology.

The mode of inquiry to determine emancipation is critical reflection. The role of reflection is gaining prominence in nursing with the regulatory body in the United Kingdom advocating its use (NMC, 2002). Generally, the role of reflection in nursing is associated with highlighting problems and learning from mistakes. It is less commonly used to promote emancipation.

Emancipatory reflection uses both the technical and practical assumptions of critical theory that provides the means to challenge the status quo politically or socially (Taylor, 1998). This involves a process of becoming critically aware and of gaining insight into individual circumstances. It entails questioning how and why our knowledge of the world in which we live constrains our way of thinking (Boud et al., 1985). Emancipatory reflection seeks to provide transformative action for those nurses wishing to be free from oppressive forces limiting their practice (Taylor, 2001b). EBP by adhering to technical science lacks the capacity to accept reflection thus leaving the way open for clinical effectiveness to embrace it in initiating emancipation.

Reflection as a means to emancipation has it its critics. According to McCarthy (1978), Habermas' claims that self reflection will lead to the truth are excessive. Reflection is subject to revision and rejection and McCarthy believes that dialogue with others is crucial in coming to an understanding despite Habermas' belief to the contrary. McCarthy (1978) also argues that reflection is limited as it is situated within a context and that we bring to it our preconceptions and prejudgements. Theunissen (1999) queries the possibility of reflection ever freeing itself from all ideological distortion, as Habermas would assert.

The translation of universal emancipation to clinical effectiveness is also a challenge. For example, clinicians can individually practice the principles of clinical effectiveness, but its general uptake is unlikely in the absence of positive role models, facilitative management and a positive context (Kitson et al., 1998). Only then would emancipation via clinical effectiveness be a possibility.

Taylor's (2000) model of reflection is incorporated into the proposed model (Figure 2) as a vehicle to emancipate clinical effectiveness. Her model is based on Habermas' three knowledge constitutive interests and as such creates an ideal framework to progress clinical effectiveness.

A consideration of the knowledge constitutive interests for clinical effectiveness

Application of Habermas' knowledge constitutive interests to clinical effectiveness would have to be of functional value otherwise there would be little point in the endeavour. Applying this criterion they could appear lacking. For example, given that technical and practical knowledge could be invoked, one is not guided towards which one would take precedence if a situation arose where both could have a role to play. Rolfe (1998) claims that the technical solution would inevitably take precedence in EBP. Whereas if clinical effectiveness incorporates both technical and practical knowledge as has been previously argued (Lipp, 2002); critical theory has the potential to give more equilibrium to clinical decision making.

It is essential that Habermas' knowledge constitutive interests only be applied to clinical effectiveness with caution as they can be accused of dominating on three levels. Firstly, Habermas' critical theory risks applying its own normative prejudices to arbitrate between false and correct (Freire and Shor, 1987). Thus, there is a risk of oppression of those who subscribe to it. Secondly, critical theory is said to be convinced of its own value and does not suggest itself for acceptance, but demands that society adopt it, a rather severe recommendation by any standard (Geuss, 1981). Thirdly, critical theory is undeniably critical of any philosophy that differs from it. Other philosophies are criticised as being put to the test of its 'annihilating judgement' (Theunissen, 1999). These criticisms do not reflect the emancipatory essence of critical theory and seriously undermines its potential for use with clinical effectiveness.

Conclusion

Despite the above criticisms and complex issues surrounding Habermas' knowledge constitutive interests there is potential for them to progress and emancipate clinical effectiveness. Technical knowledge promotes evidence based practice, practical knowledge endorses interpretive knowledge and emancipatory knowledge gives both nurses and patients the potential of freedom. The strength of Habermas' knowledge constitutive interests is in their inclusion of interpretive knowledge and the goal of emancipation. Counter to this inviting fit is the unwieldy and complex nature of critical theory combined with Habermas' turgid style that lacks clarity (Lechte, 1994). This could deter nurses seeking clarification. A compromise to exploit the best of critical theory for use with clinical effectiveness could be the development of a straightforward model such as the one I have embarked on (Figure 2). In this way, the puzzle as to whether the emergence of clinical effectiveness will have a liberating or oppressive effect upon health care can be explored via critical theory.

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