title: Representing voices from the life-world in evidence-based practice.
abstract: BACKGROUND
  Current models of evidence-based practice marginalize and even silence the voices of those who are the potential beneficiaries of assessment and intervention. These missing voices can be found in the reflections of clients on their own life-world experiences.
  
  
  OBJECTIVE
  This paper examines how voices from the life-world are silenced in current models of evidence-based practice and why this is inappropriate. It is argued that personal experience narratives rooted in the inter-subjective life-worlds of clients - currently conceptualized as mere anecdotal information or consumer opinion in evidence-based practice - should be elevated to the status of a bona fide unit of analysis in the construction of evidence. The aim is not to supplant more traditional, objective units of measurement, but, rather, to enhance our ability to interpret the ecological validity of evidence by listening to our clients' voices.
  
  
  METHODS
  Written discourse from professional position statements, technical reports, and other sources of information are analysed in terms of how they conceptualize evidence within evidence-based practice. Findings from this analysis are then compared with personal experience narratives from clients, and significant others, reflecting on the outcomes of assessment and intervention practices.
  
  
  RESULTS
  Analysis reveals that current quality of evidence hierarchies in evidence-based practice are based on an epistemology of logical positivism. They privilege cause-effect explanations grounded in objective, empirically testable variables that exist external to the self. Unfortunately, the dismissal of subjective, phenomenally oriented information has functioned to marginalize and silence voices from the life-worlds of clients when constituting proof of effectiveness. When these voices are excluded, our understanding of the social significance, magnitude and ecological validity of evidence is compromised. The current version of EBP needs to be reformulated to include subjective voices from the life-worlds of clients as a form of evidence. Toward this end, the personal experience narrative is proposed as one potential qualitative unit of analysis for characterizing the life-world outcomes of assessment and intervention. These narratives seem well suited to the task of representing social outcomes because of their attention to the particularities and consequences of human experience, and because of the way time is represented retrospectively.
  
  
  CONCLUSIONS
  To understand the complex nature of communication disorders and the efficacy of our helping practices requires not only the analysis of objective material phenomena like part-word repetitions, phonemes and morphemes, but also an examination of how these phenomena are interpreted and valued as forms of communication by clients and significant others in the life-world. Personal experience narrative is suggested as one means for understanding experienced outcomes. Other qualitatively oriented methodologies and concepts associated with ethnography of communication and discourse analysis will undoubtedly be useful in this regard.
authors.affiliation: Department of Communicative Disorders, University of Rhode Island, Kingston, RI 02881, USA. dana@uri.edu
authors.forename: Dana
authors.initials: D
authors.lastname: Kovarsky
mesh_terms: D003147:Communication Disorders / Q000523:psychology*; D019317:Evidence-Based Medicine; D006801:Humans; D008016:Life Change Events; D033262:Narration; D013066:Speech-Language Pathology