How Evidenced Based Practice Supports Inequality

Guest contributor: Mike Taylor,
Member, Nursology Theory Collective

About six years ago, the Maryland Department of Health sponsored a conference for all state stakeholders with an interest in chronic disease, including nursing and medical groups, hospitals, EMS and diabetes product companies. The latest evidenced based practice models were being presented but I was only half listening because I, like most of those in the room, already knew what we were going to hear. Which is what happened, in session after session we heard that non-white patients had the highest incidence in all chronic disease states, probably related to genes or culture, and the major solutions were primarily public awareness and ethnic specific education without any mention of the role of racism.

So, I decided to shake things up and during the break went to the Department of Health table in the exhibit hall and asked the two representatives there if we were ready to tackle institutional racism or if we were still playing around the edges. Looking unsure what to say, one of them responded “we are still playing around the edges” but offered that there was a new director who may be willing to talk with me and she would send her over to my table. She never came and the chance for a different conversation ended there.

While the department of health representatives didn’t deny the existence of institutional racism, unless evidence of institutional racism and other inequalities are allowed to be presented as part of the discussion nothing will change.

In addressing institutional racism, we tend to spend 80% of our time on awareness which is only 20% of the problem and not on changing institutions which is 80% of the problem. In this first of a series of blogs, I will argue that evidenced based practice (EBP) is a key component of the institutional structures that support racial and economic inequalities. The evidence about any clinical subject is often contradictory even in well-designed studies which is not a problem but simply a feature of the difficulty of doing science. The fact that the evidence found in scientific journals provides a range of possible answers, requires practioners, practice organizations and health systems to make choices about what evidence to include and not to include in their own practice and in practice guidelines. The science of EBP may appear to be objective but the process of choosing the subject and design of studies along with what evidence to use and how to use it is inherently subjective and open to bias that perpetuate economic and racial inequalities.

Institutional selection of what evidence to include in policy and practice is based on the degree of fit with an existing institutional theory. The institutional theories that support inequalities in race and poverty, are unspoken but widely accepted theories of health without theoreticians and based on unquestioned assumptions which can make them hard to challenge.

If we in the Nursing Theory Collective specifically and in nursing in general, are to undertake this fight to change the intertwined histories of these inequalities we must concentrate on changing the institutions and the false assumptions they are based on, and demand alternatives. Follow-up blogs will examine the use of EBP in supporting three areas of institutional inequalities including the maintenance of structural racism, control of nursing practice and control of patient autonomy. Please reach out to me and tell me what assumptions you have found in your work that you feel need to be questioned.

About William (Mike) Taylor

Mike Taylor is an independent nursing theorist specializing in the application of complexity science to health and compassion. His Unified Theory of Meaning Emergence takes a major stride in connecting the mathematics of complexity with self-transcendence and compassion. He has spoken at international, national and regional conferences on complexity in nursing, health, and business. He is a member of the board of the Plexus Institute where he is the lead designer of the Commons Project, a web based platform for rapid social evolution in climate change.

5 thoughts on “How Evidenced Based Practice Supports Inequality

  1. Excellent blog Mike! I look forward to your series! This is a very important conversation nurses need to have, and also, nurse scientists need to explicitly address in their research!

  2. “The science of EBP may appear to be objective but the process of choosing the subject and design of studies along with what evidence to use and how to use it is inherently subjective and open to bias that perpetuate economic and racial inequalities.” This observation immediately took me back to a paper that had a profound impact on me in the early days of ANS, Volume 1, #4, (correction – Vol 1 #2). The Value Decisions We Know As Science, by Robert Tucker. I encourage anyone who hasn’t read this foundational classic to dig it out and read it. It is SO relevant to this particular discussion.

  3. Hi Mike — I totally agree that there is bias in the selections of EBN topics. For example, I have yet to see the effect of White RN and White NP behaviors that communicate a high degree of racism on People of Color outcomes e.g., increased number of complications, delayed recovery, poor chronic illness control, increased pain/discomfort, increased inflammatory responsiveness, increased morbidity overall, premature mortality versus the outcomes obtained when White RN and White NP behavior does not communicate racism or communicates a low level of racism.

    We don’t even have a colonial-derived or White nurse racial superiority assessment form yet we have metrics for sepsis, UTI, fall risk, etc. When this subject has been broached so far, the response I have received is silence. Yet, if we don’t access and diagnose White RN and White NP micro aggressive behaviors we will not be able study the extent to which those behaviors are linked to poor patient outcomes.

    i have a beginning assessment tool looking at microaggressions divided into invalidations/dismissive behavior, invalidation of the experience of racism, excusión behavior, rejection behavior. The behaviors are based on limited primary data and the literature.

    But what is needed is for another team to take the lead or for an organization to take the lead preferably powerful Black nurse researchers working with powerful White nurse researcher allies. Anyone from the Nursology community interested? I am interested in either positive or negative feedback — only way I can learn. Thanks for listening.

Leave a Reply