Nurses use of research information in clinical decision making Dr Carl Thompson Centre for Evidence Based Nursing Medical Research Council Department of.

Nurses use of research Nurses use of research information in clinical decision information in clinical decision

makingmaking

Dr Carl Thompson Dr Carl Thompson

Centre for Evidence Based NursingCentre for Evidence Based Nursing

Medical Research CouncilMedical Research Council

Department of HealthDepartment of Health

Evidence from

research

Clinical

expertise

Patient

preferences

Available

resources

Evidence

Based Decision

The studiesThe studies Subjects: health visitors, practice nurses, district nurses, nurse Subjects: health visitors, practice nurses, district nurses, nurse

practitioners, acute surgical, medical and coronary care nurses.practitioners, acute surgical, medical and coronary care nurses.

Mixed method, multi-site case study design, 3 geographical Mixed method, multi-site case study design, 3 geographical areas over one year (1999-2000; 2001-2)areas over one year (1999-2000; 2001-2)

In depth interviews (n=180) In depth interviews (n=180) Observation data (600 hours)Observation data (600 hours) Q methodological statistical modelling (n=224)Q methodological statistical modelling (n=224) Local information resource audit (circa 1500 source documents)Local information resource audit (circa 1500 source documents)

sampling frame (Thompson 1999), between method & subject sampling frame (Thompson 1999), between method & subject triangulation; multi-rater Kappatriangulation; multi-rater Kappa

Information use in decision Information use in decision making contextmaking context

Uncertainty is inescapableUncertainty is inescapable Decision making is often ‘missing link’ in Decision making is often ‘missing link’ in

models of research utilisationmodels of research utilisation Adding value to what we knowAdding value to what we know Decisions affect the ways we think and the Decisions affect the ways we think and the

knowledge requiredknowledge required Expertise is not enough Expertise is not enough

WE NEED TO KNOW MORE ABOUT WE NEED TO KNOW MORE ABOUT DECISION TASKS AND RESPONSES OF DECISION TASKS AND RESPONSES OF NURSESNURSES

Adverse events and errorsAdverse events and errors

11% of admissions11% of admissions

850,000 adverse events deaths 850,000 adverse events deaths & permanent disability& permanent disability

Between 7 and 8.4 additional Between 7 and 8.4 additional bed days per adverse eventbed days per adverse event

NPSA 2002

What do we know?What do we know?

Decision based uncertainty finiteDecision based uncertainty finite Rx, Dx, communicating risks and benefits, Rx, Dx, communicating risks and benefits,

prevention, referral, targeting, timing, SDO, prevention, referral, targeting, timing, SDO, information seekinginformation seeking

One choice every 10 minutes in acute One choice every 10 minutes in acute carecare

No escaping the exercising of judgement No escaping the exercising of judgement and decisions (making a difference)and decisions (making a difference)

The questions nurses ask….The questions nurses ask…. What percentage of Diabetics taking Viagra find it effective What percentage of Diabetics taking Viagra find it effective

and how does this compare to non-diabetics taking the drug?and how does this compare to non-diabetics taking the drug?

How long should a patient continue to take a B-Blocker for How long should a patient continue to take a B-Blocker for post MI?post MI?

What is the evidence to suggest MMR is a safe vaccine?What is the evidence to suggest MMR is a safe vaccine?

What are the benefits of Breast feeding a child after the first What are the benefits of Breast feeding a child after the first year of life?year of life?

What is the most effective way to treat cracked nipples?What is the most effective way to treat cracked nipples?

What is the most appropriate pain relief regime for a What is the most appropriate pain relief regime for a terminally ill patient with bone pain?terminally ill patient with bone pain?

The information responseThe information response

270 hours of observation ‘external’ 270 hours of observation ‘external’ resources used: resources used: 19/115 patients (district nurses); 19/115 patients (district nurses); 57/224 patients (practice nurses and nurse 57/224 patients (practice nurses and nurse

practitioners); practitioners); 15/55 patients (health visitors). 15/55 patients (health visitors).

75%of these for pharmaceutical 75%of these for pharmaceutical information needs.information needs.

85% of ‘external sources’ other colleagues 85% of ‘external sources’ other colleagues or PCT members otherwise BNF (x2 on-line) or PCT members otherwise BNF (x2 on-line)

Information useInformation use

Access and usefulness – human sources Access and usefulness – human sources overwhelmingly accessible and most useful overwhelmingly accessible and most useful

BarriersBarriers the need to bridge the skills and knowledge gapthe need to bridge the skills and knowledge gap using information format to maximise limited using information format to maximise limited

opportunities for consumptionopportunities for consumption limited access in the context of limited timelimited access in the context of limited time

time (caveat) time (caveat) HV 24 minute consultations, PNs 5 mins, acute care HV 24 minute consultations, PNs 5 mins, acute care

nurses <5 mins and not consultation based;nurses <5 mins and not consultation based; dedicated nature of information seeking; dedicated nature of information seeking; opportunity costs)opportunity costs)

one: only objective information one: only objective information is valuableis valuable

Normatively – possiblyNormatively – possibly

Descriptively - untrueDescriptively - untrue

Two:more information is betterTwo:more information is better

Problem is making sense of Problem is making sense of existing information rather existing information rather than adding to it.than adding to it.

Increasing the flow of info as Increasing the flow of info as a route to knowledgeable a route to knowledgeable doers is not the answerdoers is not the answer

Three: objective information can Three: objective information can be transmitted out of contextbe transmitted out of context

Nurses reject ‘acontextual’ Nurses reject ‘acontextual’ information sources in favour information sources in favour of context-rich adviceof context-rich advice

Lack the appraisal skills to Lack the appraisal skills to inject context into informationinject context into information

Four: information can only be Four: information can only be acquired from formal sourcesacquired from formal sources

Information is ‘differences that Information is ‘differences that makes a difference’ (Bateson 1979) makes a difference’ (Bateson 1979)

Differences that made a difference Differences that made a difference (with the exception of drug-(with the exception of drug-reference material) are informally reference material) are informally locatedlocated

Five: relevant information exists Five: relevant information exists for every needfor every need

Nurses don’t recognise (or cannot Nurses don’t recognise (or cannot verbalise) information needsverbalise) information needs

Satisficing Satisficing

Nurses (like doctors) may acquire Nurses (like doctors) may acquire [over] confidence quickly (Urquhart [over] confidence quickly (Urquhart 1999). 1999).

Six: every information need Six: every information need situation has a solutionsituation has a solution

Information seeking = Information seeking = transforming need into transforming need into workable formatworkable format

unfitness for purpose = unfitness for purpose = negative feedbacknegative feedback

Seven: information can always Seven: information can always be made accessiblebe made accessible

Physical sense = yesPhysical sense = yes

Intellectual/cognitive = noIntellectual/cognitive = no

Eight: functional units of information Eight: functional units of information sources fit the needs of individuals sources fit the needs of individuals

EBN functional units = systems, EBN functional units = systems, synopses, syntheses and studies synopses, syntheses and studies (Haynes 2001)(Haynes 2001)

Nurses functional units = Nurses functional units = colleague advice, ideas and colleague advice, ideas and consultationconsultation

intuition

‘pure’ scientific experiment

Peer aided judgement

System aided judgement

good

Task Structure

poor

+

Time,VisibilityOf process

-

intuition Analysis

(cf. Hammond, Hamm, Dowie 1963-2002)

Nine: time and space ignored

Ten: easy conflict free connections between Ten: easy conflict free connections between external information and internal realityexternal information and internal reality

Defensiveness and conflictDefensiveness and conflict

We simply do not know!We simply do not know!

conclusionconclusion

““Ask not what information Ask not what information does to people but what does to people but what people do to information” people do to information” (Brenda Dervin 1976)(Brenda Dervin 1976)