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Nurses use of research information in clinical decision making. Dr Carl Thompson Centre for Evidence Based Nursing Medical Research Council Department of Health. The studies.
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Nurses use of research information in clinical decision making Dr Carl Thompson Centre for Evidence Based Nursing Medical Research Council Department of Health
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
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
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
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)
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?
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)
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)
one: only objective information is valuable • Normatively – possibly • Descriptively - untrue
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
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
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
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).
Six: every information need situation has a solution • Information seeking = transforming need into workable format • unfitness for purpose = negative feedback
Seven: information can always be made accessible • Physical sense = yes • Intellectual/cognitive = no
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
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
Ten: easy conflict free connections between external information and internal reality • Defensiveness and conflict • We simply do not know!
conclusion • “Ask not what information does to people but what people do to information” (Brenda Dervin 1976)