REVIEW

A review of evidence-based practice, nursing research and reflection:

levelling the hierarchy
Stefanos Mantzoukas BS c (Nursing), BS c (Health Studies), MS c, P hD, RGN, P gD ip (Social Research
Methods), P gC ert T&L
Lecturer in Adult Nursing, Institute of Health & Human Sciences, Thames Valley University, London, UK

Submitted for publication: 2 June 2006

Accepted for publication: 17 October 2006

Correspondence: M A N T Z O U K A S S ( 2 0 0 8 ) Journal of Clinical Nursing 17, 214–223

Stefanos Mantzoukas A review of evidence-based practice, nursing research and reflection: levelling the
22 Brentmead Gardens hierarchy
Park Royal
Aim. This paper examines the evidence-based practice movement, the hierarchy
NW10 7DS London
of evidence and the relationship between evidence-based practice and reflective
UK
Telephone: þ44 0208 280 5357
practice.
E-mail: smantzoukas@hotmail.com Background. Evidence-based practice is equated with effective decision making,
with avoidance of habitual practice and with enhanced clinical performance. The
hierarchy of evidence has promoted randomized control trials as the most valid
source of evidence. However, this is problematic for practitioners as randomized
control trials overlook certain types of knowledge that, through the process of
reflection, provide useful information for individualized and effective practice.
Method. A literature search was undertaken using CINAHL, medline and Ovid
electronic databases in early 2006. The search terms used were: evidence-based
practice, research evidence, evidence for practice, qualitative research, reflective
practice, reflection and evidence. Other sources included handpicking of books on
evidence-based practice, reflection and research. Only material written in English
was included.
Findings. The hierarchy of evidence that has promoted randomized control trials
as the most valid form of evidence may actually impede the use of most effective
treatment because of practical, political/ideological and epistemological contra-
dictions and limitations. Furthermore, evidence-based practice appears to share
very similar definitions, aims and procedures with reflective practice. Hence, it
appears that the evidence-based practice movement may benefit much more from
the use of reflection on practice, rather than the use of the hierarchical structure of
evidence.
Conclusion. Evidence-based practice is necessary for nursing, but its’ effective
implementation may be hindered by the hierarchy of evidence. Furthermore,
evidence-based practice and reflection are both processes that share very similar
aims and procedures. Therefore, to enable the implementation of best evidence in
practice, the hierarchy of evidence might need to be abandoned and reflection to
become a core component of the evidence-based practice movement.
Relevance to clinical practice. Provides an elaborated analysis for clinical nurses
on the definition and implementation of evidence in practice.

214 Ó 2007 The Author. Journal compilation Ó 2007 Blackwell Publishing Ltd
doi: 10.1111/j.1365-2702.2006.01912.x
Review
Key words: evidence-based practice, hierarchy, nurses, nursing, reflection
Introduction
It is unequivocal that evidence-based practice (EBP) has
become an imperative for clinical decision making of
contemporary nurses. Furthermore, an explicit link has
been drawn between EBP and the findings from randomized
control trials (RCT). RCTs are situated at the top of the
hierarchy of evidence and are considered to be the most
valid form of evidence, whereas other forms of evidences
emerging from reflective processes are regulated by being
projected as weak or invalid evidences (Ellis 2000, Lake
2006, Morse 2006b, Rolfe & Gardner 2006). This paper
will examine if the rationale of a hierarchy of evidence is
justified and, perhaps more importantly, if it is useful for
nursing practice. Finally, conclusions will be drawn on the
role of EBP for nursing and on judging the validity of
evidence for practice.
Background
The aim of EBP from its’ early days in the form of evidence-
based medicine was to provide the appropriate means for
making effective clinical decisions, for avoiding habitual
practice and for enhancing clinical performance (Evidence-
Based Medicine Working Group 1992, Davidoff et al. 1995).
As nurses increasingly have acquired active participation in
decision making in practice the need for effective and
justifiable decisions that would lead to enhanced practice
via the use of best evidence has been considered crucial.
Furthermore, policy, political and professional imperatives
have further made EBP a clinical prerequisite for daily
practice (Department of Health 1999, Royal College of
Nursing 2003, Holleman et al. 2006, Rycroft-Malone 2006).
Notwithstanding the imperative of EBP for current nur-
sing, nonetheless, two fundamental questions remain largely
unclear about the EBP movement. Firstly, what justifies
‘something’ as evidence and secondly, when practitioners are
faced with two opposing sets of evidence, which of the two
prevails. For some writers, the first question is considered to
be a clear-cut issue suggesting that research findings, clinical
expertise, expert knowledge, patient preferences, policy
reports and benchmarking data are the constitutional com-
ponents of evidence (Goode & Piedalue 1999, Ingersoll 2000,
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EBP, nursing research and reflection: levelling the hierarchy
Kitson 2002). Furthermore, the second question similarly
appears to be answered as well, by arranging the above
components into a hierarchy with the findings from
systematic reviews of RCTs and single RCTs to be considered
as the highest level of evidence and the rest to be considered
as lower level evidence (Sackett 1993, McKenna et al. 2000,
Page & Meerabeau 2004, Morse 2006a). Hence, in case of a
dispute between two opposing sets of evidence, obviously the
one higher up the hierarchy will prevail.
However, this is problematic for a set of other writers,
firstly, because such linearity and orderliness as is prescribed
by the hierarchy of evidence does not exist in the reality of daily
practice. Daily practice, in contrast to well designed and
executed RCTs, is complex and uncertain. The findings of
research trials are usually not directly transferable to individ-
ual patient cases because of the multiple and diverse charac-
teristics of each patient that are not fully compatible to those
patients that responded positively in the trial (Franks 2004,
Rolfe & Gardner 2006, Jenicek 2006). Secondly, practicing
nurses do not always use RCTs to make daily clinical
decisions. In fact, the majority of daily nursing decisions are
based on various other types of knowledge that do not emerge
from RCTs, such as experiential knowledge, personal knowl-
edge, practice knowledge, practical knowledge, aesthetic
knowledge and ‘knowing-how’ knowledge (Reed et al. 1997,
Edwards 2001, Geanellos 2004). Thirdly, the relevant hier-
archy of evidence ignores or discourages the use of various
types of research and knowledge because they are considered
as ‘weaker’ or ‘lesser’ evidence and an imperative is expressed
for the re-conceptualization of evidence and the need to
produce new definitions for EBP (Buetow & Kenealy 2000,
Jennings & Loan 2001, Gilgun 2006, Morse 2006a). Lastly,
current articles are still unclear about the nature of evidence in
EBP and continue to ask the question ‘what counts as evidence
in EBP’ (Lake 2006, Whalle et al. 2006).
Therefore, the aim of this paper is to analyse critically the
aims, intentions and processes of the EBP movement, to
identify if these aims and intentions are best achieved in
nursing by using RCTs and to explore the relationship
between the EBP process and the reflective process. Eventu-
ally, conclusions will be drawn on the role of the EBP
movement for nursing, on the usefulness of the hierarchy of
evidence and on the relationship between EBP and reflection.
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S Mantzoukas
Method
A search of the published literature on EBP, nursing research
and reflection was conducted in early 2006 using the
electronic databases CINAHL, Ovid and Medline. The
following keywords were used: EBP, research evidence,
evidence for practice, qualitative research and evidence,
reflective practice and EBP, reflection and evidence. The
search was restricted to English language articles and it
yielded 1114 references. Initially the titles of the retrieved
material were reviewed and from this initial review approxi-
mately 400 articles were rejected, because the keywords were
part of a journal’s title, rather than of an article. Conse-
quently, the abstracts were screened and from this process
over 500 articles were excluded because the concept of EBP,
research and reflection were not the prima foci of the article
or because the articles superficially used these terms or
because some of the articles were duplicated in the search
process. The electronic search was supplemented by search
and handpicking of books from the university library on the
relevant topics. Eventually, a total of 200 full text articles
and 16 book chapters were included in the review.
The data were read and re-read by the author as to acquire
an in-depth understanding of the phenomena and achieve
data saturation, a technique that the literature requires for
qualitative reviews as the present one (Booth 2001, Jones-
Lloyd 2004). The data were reduced to a total of 66 articles
and book chapters with special attention taken as to include a
comprehensive list of seminal articles and articles with
conflicting arguments.
Findings
Defining and implementing evidence-based practice
It is avowedly accepted by the nursing literature that EBP is
not only a timely catchphrase or mantra (Jenicek 2006,
Rycroft-Malone 2006) but, most importantly, it is a phrase
associated with science, rationality and best practice and any
argument opposing it is seen as irrational, unscientific and
potentially dangerous (Walker 2003, Rolfe 2004, Rycroft-
Malone 2006). The literature seems to inextricably align EBP
with best practice (Walker 2003, Tolson et al. 2005), with
doing the right thing (Muir-Gray 1997), with avoiding
harmful interventions (Brocklehurst & McGuire 2005) and
with transparent, accountable and legally defensible decisions
(Page & Meerabeau 2004, Parahoo 2006).
Indeed, advocates for basing practice on evidence have up
to a point cogently argued that practice on hearsay, ritual,
route and intuition should be avoided. The initial and
216 Ó 2007 The Author. Journal compilation Ó 2007 Blackwell Publishing Ltd
probably most quoted definition of evidence-based medicine,
which is the forerunner of the EBP movement, suggests the
de-emphasis of ‘intuition, unsystematic clinical experience
and pathologic rationale’ for clinical decision making and
instead places emphasis on ‘the examination of evidence from
clinical research’ (Evidence-Based Medicine Working Group
1992). The use of up to date research is considered on one
hand to be a ‘more scientific’, legitimate and sound approach
for clinical decision making and on the other hand it is
anticipated that it can eliminate irrational acts or guess work
from daily practice (Page & Meerabeau 2004, Rashotte &
Carnevale 2004). Eventually, decisions that are based on
scientific clinical research are considered to increase effec-
tiveness, to minimize the possibility of error and to
standardize practice (Rashotte & Carnevale 2004, Parahoo
2006).
Intriguingly, and perhaps ironically, while the initial
definition of EBP movement assiduously rejected intuition,
routine practice and unarticulated experience, more recent
definitions partly re-treat from this initial view to incorporate
experiences, individual perceptions and tacit ways of
knowing of both health professionals and patients. For
instance, Sackett et al. (1996) following the position paper
of the EBMWG went on to emphasize that ‘the practice of
evidence-based medicine means integrating individual clinical
expertise with the best available external clinical evidence
from systematic research’ (p. 71). French (2002) moves even
further away from the initial EBM definition, to suggest
that EBP is ‘the systematic interconnecting of scientifically
generated evidence with the tacit knowledge of the
expert practitioner’ (p. 253). Equally, Kitson (2002) proposes
that:
‘EBP should embrace ways of being able to demonstrate the effective-
ness of expert knowledge on individual and collective patient decisions;
the impact of existing research and outcomes and the ability to
integrate patient experiences into decisions about outcome’ (p. 181).
Similarly, MacPhee and Pratt (2005) expand the definition of
evidence beyond research data, benchmark data and internal
data, to include patient and family preferences and clinical
expertise. Lastly, Berwick (2005) also argues for the need to
broaden the definition of EBP to include everyday effective
problem-solving approaches that are different from formal
science which, in the world of clinical care, when used well
and consciously, have plausible validity.
Ineluctably and in some ways more significantly, the actual
implementation of evidence in daily practice has currently
acquired greater eminence in the health literature rather than
the definitions of EBP. The literature appears to acknowledge
that EBP is a prescriptive process of making decisions for
Review
Table 1 The process of implementing evidence in practice
Simpson (2004) considers evidence-based practice (EBP) to be
a four step process involving:
(a) the identification of the issue or problem,
(b) the search of the literature for research,
(c) the evaluation of research,
(d) the action based on the evidence.
Parahoo (2006) views EBP as a five step process involving:
(a) the formulation of a clear question related to
policy or practice,
(b) the search of relevant research studies,
(c) the appraisal of selected studies,
(d) the analysis and the synthesis of the findings,
(e) the dissemination of results and implementation of evidence.
Thomson et al. (2004) suggests that integrating evidence within
clinical reality involves a five step process involving:
(a) forming clinical question in response to a recognized
information need,
(b) searching for the most appropriate evidence,
(c) critically appraising the retrieved evidence,
(d) incorporating the evidence into a strategy for action,
(e) evaluating the effects of any decisions and actions taken.
Holleman et al. (2006) advocate that the introduction of EBP
into daily practice may involve a six step process involving:
(a) assessment of the need for practice changes,
(b) linking problem interventions and outcomes,
(c) synthesis of best evidence,
(d) design of practice change,
(e) implementation and evaluation of practice change,
(f) integration and maintenance of EBP change.
patient care and treatment (McKenna et al. 2000, Thomson
et al. 2004). The implementation of evidence in the real
world of practice as outlined by various authors (Table 1)
includes a series of steps or processes. These steps include; (i)
the analysis of the clinical reality and the formation of
questions from practice that require answering; (ii) search for
appropriate research or other literature on the relevant
practice issue; (iii) critically analyse, appraise and evaluate
these materials; (iv) synthesize or integrate these materials
with the context of clinical reality as to act and resolve the
specific problematic clinical situation; and (v) evaluate the
actions based on the research or literature information and
how they impacted (or not) on the resolution of the
problematic situation.
In summary, the EBP movement purview is understood as a
conscious, explicit and logically articulated decision-making
process that allows transparency, ensures best practice and
avoids errors that are related to rote or habitual practice.
Moreover, EBP is viewed as a process that can be compart-
mentalized in a series of steps that practitioners can follow.
Finally, despite that clinical expertise and patient preferences
have been incorporated in EBP definitions, nonetheless the
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EBP, nursing research and reflection: levelling the hierarchy
core elements of EBP remain the results from research
findings. Moreover, as it will become explicit in the following
section, it is the results from a specific type of research,
namely those emanating from clinical trials that are consid-
ered as the most valid source of evidence.
The role of nursing research in evidence-based practice
Despite the fact that recent definitions on EBP include
personal and professional experience and specific contexts
and situations, nonetheless, on closer analysis, it appears that
at the crux of the EBP movement is the promotion of research
findings as the most (if not only) justifiable form of evidence.
A series of authors have argued (either dissenting or
consenting) that RCTs and systematic reviews are in essence
the corner stone or the crown prince or the golden standard
for the EBP movement (Walker 2003, Franks 2004, Mistiaen
et al. 2004, Berwick 2005, Rycroft-Malone 2006).
Moreover, this is perpetuated by the very idea that a
hierarchy has been developed in defining the validity of
evidence (Figure 1). At the top of this hierarchy (and hence
the most valid source of evidence) are the findings from
systematic reviews of RCTs and the next level down the
hierarchy are evidence from at least one well conducted RCT.
The next three levels down the pyramid are evidence from
controlled research that lack randomization, research with-
out a control group and opinions of respected authorities.
Interestingly, the last three levels are not recommended to
inform practice, thus assuming that they are not sufficient
evidence to base practice (Sackett 1993, McKenna et al.
2000, Morse 2006b). Lastly, the introduction of guidelines
that are based on the most updated RCTs, the development
of RCT databases, the creation of evidence based journals
that contain primarily RCT abstracts and the experimenta-
tion with computerized decision supporting systems that are
based on RCT reviews, further reinforce the dominance of
Meta-analysis
of RCTs
At least one well-conducted
RCT
Controlled research without
randomization
Research without experimental study
Opinions of respected authorities
Figure 1 The hierarchy of evidence.
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S Mantzoukas
RCTs as the most valid source of evidence (Mistiaen et al.
2004, Brocklehurst & McGuire 2005, Haynes 2005, Walker-
Dilks 2005).
However, the promotion of RCTs as the most valid source
of evidence sits uncomfortably with many writers, academics
and practitioners in the health field and to such an extent is
this discontent, that some go to other side suggesting that the
EBP movement should either be re-structured or even
discarded (Walker 2003, Geanellos 2004, Hancock & Easen
2004). It is what Forbes (2003) views as the ‘danger of
throwing the baby out with the bath water’. The concerns
relating to the promulgation of RCTs as the only valid form
of evidence can be summarized into three broad aspects,
namely: practical, political/ideological and epistemological.
The first concern has to do with the impracticality of
implementing the findings of RCTs as evidence in daily
practice. It is argued that the very nature of RCTs can answer
specific and limited questions (McKenna et al. 2003, Maier
2006, Mol 2006). The questions that RCTs can answer are
ones of comparison between drugs or treatments and can
produce conclusions as to which has better effects, but not
necessarily, which is more effective. Effectiveness has to do
with meeting the needs and overall aims of the individual in
specific and unique contexts. However, because both the
individual needs and the contexts are unique, unavoidably
clinical aims and goals are also individual and unique. Hence,
what is effective treatment for a specific individual in a specific
context is determined by their unique aims and goals. The very
nature of RCTs necessitate the de-contextualization, homog-
enization and generalization and can only provide answers to
acontextual situations were goals and aims are identical and
general (van Meijel et al. 2004, Pearson et al. 2004, Ellis 2005,
Mol 2006, Morse 2006c, Rycroft-Malone 2006).
Furthermore, practitioners are busy professionals dealing
with complex and unique clinical problems that require on
the spot decisions to be made. It is, therefore, virtually
impossible to stop before every decision is to be made and re-
treat back to the library to retrieve all relevant RCTs. Hence,
either the practitioners will rely on their memory of RCTs
that they have read with the fallibility and selectivity that this
entails (Newell 1992, Rolfe 2005) or will rely on guidelines as
developed from RCTs by opinion leaders with the restrictive
effect that this has on practitioners initiative and autonomy
(McKenna et al. 2000, Lorenz et al. 2005).
The second aspect of concern in promoting RCTs as the
most valid form of evidence for practice are the underlying
political and ideological assumptions. To put it more bluntly
and perhaps fairly cynically, part of the literature propounds
that the ideology of professional control and the operation of
power, authority and economy has significantly contributed
218 Ó 2007 The Author. Journal compilation Ó 2007 Blackwell Publishing Ltd
in equating the EBP movement with research emanating from
RCTs. Larner (2004) adamantly suggests that it ‘is not a
question of evidence or no evidence, but who controls the
definition of evidence and which kind is acceptable’ (p. 20).
In simple terms, endorsing RCT findings as the most valid
source of evidence is to remove the expertise and authority
from the practitioners in defining practice and bestowing this
expertise and authority to researchers, academics and educa-
tionalists. Practitioners do not have the time or the resources
and in some cases the expertise to carry out or appropriately
critique RCT studies. It is researchers, academics and
educationalists that usually carry out RCTs or review and
critique them. However, researchers, academics and educa-
tionalists are mainly not involved in the reality of daily
practice and cannot have control, if the findings of their RCT
studies will ever be implemented in practice. Therefore, the
only way for these professional groups to make sure that their
research will acquire significance is to impose their findings
upon practitioners as the only valid form of evidence for
clinical decision making (Freshwater & Rolfe 2004, Rolfe &
Gardner 2005, Rycroft-Malone 2006). The move towards
integrating researchers, academics and educationalists in
daily practice reality and involving practitioners with
research, education and academia can become a starting
point for addressing this covert power game regarding the
validity of RCTs.
Lastly, this covert political agenda of imposing practice
decisions on practitioners is not irrelevant to what Walker
(2003) defines as ‘economic rationalism’, but rather an
extension of the politics of power. The assumption here is
that money is the ‘bottom line’ and the greater the cost
effectiveness of daily practice, the better. However, for the
most cost-effective practice to be implemented it is required
that practitioners are conditioned or controlled as to base
their practice on predefined and clear-cut guidelines with
predictable and beforehand cost estimations. Interestingly,
the people who make the decisions on the distributions of
funds are in part the same people who carry out research and
develop practice guidelines (Walker 2003, Morse 2006b,
Rycroft-Malone 2006). By controlling and standardizing
clinical practice, on the one hand, they are able to control in a
predicative fashion the expenditure of money and on other
hand, they can make sure that they impose their research
findings in practice.
Finally, the third concern in promoting RCTs as the
most valid form of evidence for practice relates to epistemo-
logical contentions. It is suggested that RCTs are not
suitable for practitioners because practice is complex, uncer-
tain, contextual and practitioners rely on more than one type
of knowledge, which RCTs are unable to accommodate
Review
(Geanellos 2004, Tarlier 2005, Rycroft-Malone 2006). In
very simple terms, this argument takes the form of positivism
vs. non-positivism debate. RCTs are considered to follow the
canons of the positivist paradigm aimed at acquiring the
objective facts, the single ‘right’ answer and the general and
unchangeable laws of nature and society (Mantzoukas 2004).
This is achieved by applying strict methodological rules of
objectivity and stringent control of contextual variables
(Mantzoukas 2005, Weaver & Olson 2006). The end result
is generalized knowledge based on explanations of objec-
tively identified phenomena (Forbes et al. 1999).
However, it is debated that the manifold variables of the
practice environment cannot be controlled and practitioners
cannot be objective because the kernel of practice is human
interactions and the understanding of subjective perceptions
(Edwards 2001, Rolfe et al. 2001). Moreover, practitioners
cannot acquire absolute or single ‘correct’ answers because
answers and solutions for daily practice need to be construc-
ted or fabricated as to fit individual cases. Thus, RCTs whilst
very useful when the aim is to acquire factual knowledge,
objective answers and predictive generalized theories, never-
theless it is of limited use when practitioners aim at
understanding individual patient perception, acquiring per-
sonal knowledge and carrying out specific activities as to care
and cater for specific patient needs (Forbes et al. 1999,
Edwards 2001, Rolfe 2006, Weaver & Olson 2006).
In fact, it is propounded that even the implementation of
the objective and generalized results of RCTs, paradoxically
require the subjective interpretation of the individual prac-
titioner. Practitioners are required to use their subjective
judgement to identify the similarities between the subjects
that participated in the study and the patient they are caring
for and interpret the benefits and harms of the specific
treatment (Lake 2006). Hence, it is assumed that, epistemo-
logically, daily practice is much closer to the interpretive or
postmodern paradigms and that the validity and value of
evidence ought to be considered by the criteria of these
paradigms (Rolfe 2004, De Simone 2006).
In summation, the EBP movement has been identified to
have a very close relation with research and specifically with
RCTs and systematic reviews of RCTs. In fact, it is projected
and has come to be accepted that RCTs are the most, if not
the only, valid form of evidence. This has been achieved
by various mechanisms, most important of which is the
development of a hierarchy of evidence. Nonetheless, the
equation of evidence with RCTs makes not only for uncom-
fortable reading in some quarters of the literature, but most
importantly for potentially ineffective practice.
Firstly, it is impractical for practitioners to base the
majority of clinical decisions on RCTs because daily practice
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EBP, nursing research and reflection: levelling the hierarchy
primarily requires on the spot decision making that RCTs
cannot facilitate. Most importantly, RCTs can only provide
limited information for practitioner as they can only inform
on which drug or treatment has better effects, if compared
with another drug or treatment, but not which is more
effective for a specific patient. Secondly, the EBP movement is
seen as a suspect enterprise where the politics or ideology of
power and economics are the ones that have defined RCTs as
the golden standard of research and the most valid form of
evidence and not their capacity for best practice. Thirdly, it is
considered that the imposition of RCTs as the only valid form
of evidence for practice revokes previous and well rehearsed
debates on epistemological issues and represents nothing
other than an attempt of the positivistic paradigm to impose
its’ methods on practitioners. However, this remains prob-
lematic because, on the one hand, the positivistic epistemol-
ogy cannot explain the complexity of daily practice and on
the other hand, the reality of practice appears to be much
closer to the interpretive and postmodern paradigms. There-
fore, for daily practice the concept of evidence carries
subjective and interpretive connotations that seem to have a
direct linkage with reflective methods of practising, rather
than with findings from RCTs.
Reflective practice and evidence
The epistemological uneasiness that positivism introduces via
the use of RCTs as the only valid form of evidence has been
rehearsed before and in another forum, namely that of
reflection and reflective practice. The disassociation of theory
from action and practice, whereby theory is developed by
strict methodological canons of research to dictate actions or
practice has been problematic for a series of philosophers,
such as Marx, Dewey and Rorty. For these philosophers
knowledge is not something that should correspond to some
antecedent truth, super-imposed reality or predefined des-
cription of the world, but rather knowledge is something
emergent that is always in a dialectical interplay with
experience and action and as such requires continuous
interpretation or re-description.
In simple words, knowledge is inextricably linked with
action and in specific with good action, with what works and
with what is effective. Therefore, knowledge should not
enclose an absolutely true picture of the world acquired
through methodological rigor of control and randomization,
but instead it should open up the possibility of various
descriptions of practice experiences and actions that would
identify the most useful or most effective experience or
action. Essentially they suggest that knowledge and advance-
ment of knowledge emerges from our interpretive
219
S Mantzoukas
descriptions of the effectiveness or not of our experiences and
actions (Gallagher 1964, Eagleton 1999, Calder 2003).
It is this concept that knowledge emerges from actions and
practice experiences that spearheaded writers as Schon
(1983) to develop the concept of reflection as means for
acquiring and developing professional knowledge. Schon
(1983, 1987) was concerned that research based knowledge
encapsulated in theories provided linear, certain and clear-cut
solutions, but practice reality is non-linear, uncertain, com-
plex and conflicting. Therefore, research based knowledge as
expressed by positivism does not provide answers to practi-
tioners and does not guarantee best practice. According to
Schon, practitioners need to implement reflective techniques
to name and frame unique problematic situations and from
there on, to find a workable unique solution to their
problems. Furthermore, Schon advocated that, by con-
sciously analysing the problematic situation and the imple-
mented actions, lessons can be learned that can be used to
inform future practice on what works and what is more
effective. Following from this health professional in general
and nursing in specific, incorporated reflection as means for
explicating practice, analysing the decision-making processes
and ensuring the provision of unique and best care.
Moreover, the nursing literature has alleged from its
conception as a profession that it utilizes various types of
knowledge, such as practical knowledge, personal know-
ledge, aesthetic knowledge and experiential knowledge
(Carper 1979, Benner 1984). Whilst, these types of know-
ledge were considered essential for providing information
necessary to treat patients in a unique, holistic and individ-
ualistic manner, nonetheless they were largely ignored
because on one hand they could not be formally developed
or taught and on the other hand they remained in the realm of
unconscious doing and intuitive practice. However, reflection
and reflective techniques of practice provided the epistemo-
logical justification of the worthiness of these types of
knowledge. Most importantly, reflection provided structure
and guidance to transpose these unconscious and intuitive
types of knowledge into conscious types and allowed for
linkages to be developed with previous knowledge, formal
theories and research knowledge. In this way, a repertoire of
cases could be build that would enable justification of
practice (Johns 1995, Rolfe 1996, Mantzoukas 2002, Jasper
2003, Johns & Freshwater 2005).
Furthermore, the literature acknowledges that knowledge
emerging from reflective analysis is a process that can be
compartmentalized in a series of steps that practitioners can
follow (Table 2). These steps include: (i) the description or
framing of feelings, situations and context; (ii) the analysis
and evaluation of the situation by using various types of
220 Ó 2007 The Author. Journal compilation Ó 2007 Blackwell Publishing Ltd
Table 2 The process of implementing reflection in practice
FitzGerald and Chapman (2000) consider that reflection is a self
awareness process that requires a series of steps:
(a) describe experiences,
(b) critically analyse situations,
(c) develop new perspectives,
(d) evaluate the learning process.
Gibbs (1988) model of reflection also suggests that reflection is a
process with distinct steps to be followed:
(a) the description of what happened and of the practitioner
feelings,
(b) the evaluation of what was good or about the experience,
(c) the analysis or sense making of the situation,
(d) the conclusions and potential alternatives in dealing with the
situation,
(e) the action plan for future practice.
Burnard (2000) views reflection as a process that entails the following
steps:
(a) identifying the context,
(b) locating the element by focusing on a particular event,
(c) reflecting on the element,
(d) disclosing, verbalizing and writing down thoughts, comments
and reactions,
(e) discuss other aspects of the activity and consider implications,
(f) summarize the process as to function as an aide memoir for
future practice.
Rashotte and Carnevale (2004) consider reflection a decision making
model that is characterized by five steps:
(a) recognition of each case as unique,
(b) framing the parameters of the unique case,
(c) drawing on experience-based repertoire of examples in order to
identify elements of the case that are familiar and unfamiliar,
(d) conducting rigorous on the spot experiments that examine
competing hypothesis,
(e) maintaining an openness towards rejecting ones prior
conclusions.
knowledge; (iii) verbalizing understandings, drawing conclu-
sions and developing a hypothesis or an action plan about the
specific situation; (iv) implementing the action plan; (v)
evaluating the outcomes of the action plan and integrating
the unique situation with other types of knowledge and
experiences.
In summary, reflection is viewed as a process of trans-
forming unconscious types of knowledge and practices into
conscious, explicit and logically articulated knowledge and
practices that allows for transparent and justifiable clinical
decision making. Thus, reflection is considered to enable
individualistic and holistic treatment of patients by providing
best practice and avoiding unfruitful and unnecessary inter-
ventions. The underpinning element of reflection is primarily
the experiences the practitioner possesses and the individual
patient with the specific needs. Equally, important is the
conscious effort of the practitioner to link this reflective
Review
knowledge with other types of knowledge and consequently,
develop a set of case repertoires. Eventually, reflection is
viewed as a process that can be compartmentalized in a series
of steps that practitioners can follow.
Discussion
Three key issues can be extrapolated from the heretofore
analysis of EBP, nursing research and reflection. Firstly, the
EBP movement is not only here to stay (Jenicek, 2006), but it
is a responsible, accountable and professional manner for
nurses to carry out their practice. However, the actual
implementation of the EBP rhetoric in practice requires some
attention as to identify what counts as evidence and how
practitioners will judge the validity of the various types of
evidence. As Forbes (2003) suggests EBP on its own is neither
bad, nor good, but it is the way it is conceptualized and used
that makes it useful or not. The very idea that EBP can lead to
best practice through conscious and logical decision-making
processes that would eventually secure maximum effective-
ness for patient care is something that no health professional
can or is willing to argue against. Thus, the fundamental aims
of the EBP movement are useful, necessary and beneficial for
both practitioners and patients and it seems appropriate for
EBP to become a core component of the nursing profession.
The second key issue that emerges is that, while findings
from RCTs have been venerably projected as the only
warrantable form of evidence for practice, nonetheless an
unwitting (or not) misconception, overestimation and overall
distortion of the value of RCTs as evidence is apparent.
Despite that, RCTs can be used as a form of evidence,
nonetheless, their value is severely curtailed by the practical
limitations they pose, by the epistemological diversity and
plurality of practice that RCTs cannot accommodate for and
by the political and ideological implications of devaluing and
limiting practitioners’ autonomy and initiative. Therefore,
projecting RCTs as the most valid source of evidence is not
only illusionary, but potentially dangerous, as it does not
secure best practice, most effective care and optimal treat-
ment.
The third and possibly most important issue that emerges is
that reflective practice and EBP are not very dissimilar ways
of practising. In fact, some nurses have come to realize that
reflection can provide not only valid evidences for practice,
but possibly is positioned in a better place to provide more
practical, useful and effective evidences (Malterud 2002,
Forbes 2003, Rolfe 2005). The broadened definitions of EBP
recognize that EBP is a decision-making process that enables
the practitioner to consciously and explicitly choose the best
treatment option for individual patients. This definition is
Ó 2007 The Author. Journal compilation Ó 2007 Blackwell Publishing Ltd
EBP, nursing research and reflection: levelling the hierarchy
very similar, if not identical, with definitions for reflection
and reflective practice. Moreover, EBP and reflection are
considered to be based on a series of successive steps or
procedures that includes; clear description of issues and
contexts, critical analysis of all variables affecting the patient
situation, the development of an action plan, the implemen-
tation of the action plan and the evaluation of the action
plan. Lastly, but possibly more importantly, the individual
practitioner, for both EBP and reflection, remain the most
important element for achieving best practice through the
rational, contiguous and logical justification of choices made.
Conclusion
Therefore, it is suggested that the aims of the EBP movement
are important and necessary aspiration for nursing practice.
Moreover, the hierarchy of evidence with RCTs as the most
valid form of evidence is not only in many ways flawed, but
most importantly unsuitable for health practitioners. Lastly,
EBP and reflection are both considered processes that share
very similar aims, procedures and mechanisms. Therefore, it
seems appropriate that health professionals abandon the
hierarchy of evidence as it is portrayed by the literature and
integrate EBP with reflective practice. In other words, the
levelling or abandoning of the hierarchy of evidence will
enable practitioners to practice in a reflective manner and,
therefore, base their practice on conscious, justifiable and
explicit evidences.
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