Clinical Decision Making, Information Use and Practice Development...

1. Clinical Decision Making, Information Use and Practice Development... Dr Carl Thompson, Dr Nicky Cullum, Dorothy McCaughan, Prof..Trevor Sheldon, Prof.. David Thompson, Dr Anne Mulhall. University of York, CEBN, 2000

2. For the snoozers... • Nursing decisions ARE amenable to research evidence… • clinical questions rarely involve blue vs black pens! • Text based resources bad… human clinically credible experts good. • Bureaucratic PDN validation bad… PDN as ‘expert’, reflexive source of implementation advice good. • Diagnosis...targeting…marketing… meaningful follow up all good

3. WHY? The research questions • The potential for EBN • what kinds of decisions do nurses make? • what stops them using research in practice? • how do they access information for practice? • how useful do they find research information?

4. How? The methods... • NHS R&D: Methods to improve the implementation of research findings • 3 large case sites (+ 2 pilots) Medicine, Surgery, CCU • qualitative • 108 interviews • 180 hours of observation • 4000 ward based documents audited • quantitative • 122 x3 Q sorts - used to model shared sets of values around key questions • regression modeling of associated demographics • Analysis: between method and case triangulation, cross comparison.

5. What…some of the results • Nurses make decisions! • selecting interventions • targeting • timing • communicating risks and benefits • hermeneutic/experiential • service organisation, delivery and management

6. They can convert these decisions into Evidence Based PICO questions • E.g. • In elderly and inactive patients, who may require surgical intervention, which is the most suitable pressure relieving mattress to prevent pressure sores? • Is there a risk assessment tool available that will accurately predict which group of patients will benefit most from anti-embolic stockings? • When to commence asthma education on newly diagnosed asthmatics to make sure that self management is most effective ? • Would I be better talking and explaining rehab with the patient’s family present so that a clear understanding is obtained prior to the patient’s discharge? • How should I organise handover so that the most effective form of communicating information results?

7. What stops nurses using research? • don’t understand? • low confidence • colleagues • low skills and low motivation.

8. Improve access then? • Don’t use text based resources • 180 hours: 4 protocols, BNF and errr… that’s it! • 4000 documents: average age 5 years, 42% had audit trail only 10% any kind of evidence base. • Human sources dominate

11. But we are useful... • Yes and no! • your products are seen as useful… as part of the machinery of a Trust less so. • Need • guiding or prescriptive messages • combined with experience • structurally supported development processes • technology based

12. Implications then…general • Work with what you have got…diagnoses (NHS CRD, 1999) • target • market • multifaceted interventions • meaningful follow up

13. Implications… PDNs • Bridging roles: EBN as well as practical skills • generic roles… ‘fire fighting’ • reactive as well as proactive • market your efforts - publish, expose to scrutiny (not just other PDNs!) • clinical credibility and applicability = currency for change NOT research process • Harness the power of change agents

14. The vision? ‘they [Practice Development Nurses] facilitate innovation and the development of research-based clinical practice within clinical areas. They have a a broad clinical nursing foundation, together with a high level of skill and knowledge relevant to leadership, management of change and use of research in nursing practice.’

15. How not to achieve it... • Bottom line: clinical relevance is the key to successful research and organizational change… • Nurses make decisions • These decisions are often associated with uncertainty • Nurses can (if given the opportunity) convert uncertainty into focused (answerable) clinical questions. • Provide help in getting the answers to those questions… valid role for PDNs??