Nurses use of research information in clinical decision making

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

3. The studies • Subjects: health visitors, practice nurses, district nurses, nurse practitioners, acute surgical, medical and coronary care nurses. • Mixed method, multi-site case study design, 3 geographical areas over one year (1999-2000; 2001-2) • In depth interviews (n=180) • Observation data (600 hours) • Q methodological statistical modelling (n=224) • Local information resource audit (circa 1500 source documents) • sampling frame (Thompson 1999), between method & subject triangulation; multi-rater Kappa

4. Information use in decision making context • Uncertainty is inescapable • Decision making is often ‘missing link’ in models of research utilisation • Adding value to what we know • Decisions affect the ways we think and the knowledge required • Expertise is not enough WE NEED TO KNOW MORE ABOUT DECISION TASKS AND RESPONSES OF NURSES

5. Adverse events and errors • 11% of admissions • 850,000 adverse events deaths & permanent disability • Between 7 and 8.4 additional bed days per adverse event NPSA 2002

7. What do we know? • Decision based uncertainty finite • Rx, Dx, communicating risks and benefits, prevention, referral, targeting, timing, SDO, information seeking • One choice every 10 minutes in acute care • No escaping the exercising of judgement and decisions (making a difference)

8. The questions nurses ask…. • What percentage of Diabetics taking Viagra find it effective and how does this compare to non-diabetics taking the drug? • How long should a patient continue to take a B-Blocker for post MI? • What is the evidence to suggest MMR is a safe vaccine? • What are the benefits of Breast feeding a child after the first year of life? • What is the most effective way to treat cracked nipples? • What is the most appropriate pain relief regime for a terminally ill patient with bone pain?

9. The information response • 270 hours of observation ‘external’ resources used: • 19/115 patients (district nurses); • 57/224 patients (practice nurses and nurse practitioners); • 15/55 patients (health visitors). • 75%of these for pharmaceutical information needs. • 85% of ‘external sources’ other colleagues or PCT members otherwise BNF (x2 on-line)

10. Information use • Access and usefulness – human sources overwhelmingly accessible and most useful • Barriers • the need to bridge the skills and knowledge gap • using information format to maximise limited opportunities for consumption • limited access in the context of limited time • time (caveat) • HV 24 minute consultations, PNs 5 mins, acute care nurses <5 mins and not consultation based; • dedicated nature of information seeking; • opportunity costs)

11. one: only objective information is valuable • Normatively – possibly • Descriptively - untrue

12. Two:more information is better • Problem is making sense of existing information rather than adding to it. • Increasing the flow of info as a route to knowledgeable doers is not the answer

13. Three: objective information can be transmitted out of context • Nurses reject ‘acontextual’ information sources in favour of context-rich advice • Lack the appraisal skills to inject context into information

14. Four: information can only be acquired from formal sources • Information is ‘differences that makes a difference’ (Bateson 1979) • Differences that made a difference (with the exception of drug-reference material) are informally located

15. Five: relevant information exists for every need • Nurses don’t recognise (or cannot verbalise) information needs • Satisficing • Nurses (like doctors) may acquire [over] confidence quickly (Urquhart 1999).

16. Six: every information need situation has a solution • Information seeking = transforming need into workable format • unfitness for purpose = negative feedback

17. Seven: information can always be made accessible • Physical sense = yes • Intellectual/cognitive = no

18. Eight: functional units of information sources fit the needs of individuals • EBN functional units = systems, synopses, syntheses and studies (Haynes 2001) • Nurses functional units = colleague advice, ideas and consultation

19. Nine: time and space ignored + Time, Visibility Of process - good Task Structure poor ‘pure’ scientific experiment System aided judgement Peer aided judgement intuition (cf. Hammond, Hamm, Dowie 1963-2002) intuition Analysis

20. Ten: easy conflict free connections between external information and internal reality • Defensiveness and conflict • We simply do not know!

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