Download primary care nurses use of research evidence

Nurses’ use of research
information in clinical decision
making in primary care
Carl Thompson; Dorothy McCaughan; Pauline
Raynor; Nicky Cullum; Trevor Sheldon.
Funder: Medical Research Council
Clinical
expertise
Evidence
from
research
Evidence
Based
Decision
Patient
preferences
Available
resources
methods
Subjects: health visitors, practice nurses, district nurses,
nurse practitioners
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Mixed method, multi-site case study design, 3 geographical
areas over one year (2001-2)
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In depth interviews (n=82)
Observation data (270 hours)
Q methodological statistical modelling (n=120)
Local information resource audit (circa 1000 sources)
Rigour: explicit purposive sampling frame; between method &
subject triangulation; multi-rater Kappa for descriptive coding
tasks
Why information use in decision
making context?
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Finite range of uncertainties (coming next…)
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
Cognitive continuum (cf. Hammond, Hamm, Dowie 1963-2002)
‘pure’ scientific
experiment
+
good
Task
Structure
System aided
judgement
Peer aided
judgement
Time,
Visibility
Of process
intuition
-
poor
intuition
Analysis
Decision space in the real
world?
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Assume limited time
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Increasing need for visibility in decision making
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Task structure is vital to understanding the
mechanism for inducing cognition
Understand task structure – possibility of
inducing ways of thinking and different kinds of
knowledge use
Other health
information:
smoker? Mobility?
Medication?…etc
Compliance?
History: how and
when ulcer
started; current
treatment;
pain… etc
Background
information
Leg exam: oedema,
temperature; ankle
and calf
circumference…
General
medical
condition:
diabetic? RA;
anaemic?… etc
Doppler ABPI
Ulcer: size,
odour, slough,
exudates?
Investigations: urine, FBC,
ESR, urea and electrolytes,
blood glucose, swab (if
appropriate)
general condition:
well? Pulse, BP,
weight
ARTICLES
DAILY VISITS
PHYSIOLOGY
PATIENT INFORMATION
PATIENT REJECTION OF
EXPERTISE
COLLEAGUE’S
‘EXPERIMENTS’
COST
ROLE CONFLICT, GP WISHES
REJECTION OF EXPERTISE
CNS
NEED FOR
VISIBILITY IN
DECISION
SHARED DECISION
MAKING VALUES
SEEING IS BELIEVING AND EXPERIMENTATION
WOUND FORMULARY
COST
DOWN TO WHAT I’VE USED OVER THE YEARS
Stage 1: assessment
‘pure’ scientific
experiment
+
good
System aided
judgement
Task
Structure
Peer aided
judgement
Time,
Visibility
Of process
intuition
-
poor
intuition
Analysis
Stage 2: conflict
‘pure’ scientific
experiment
+
good
System aided
judgement
Task
Structure
Peer aided
judgement
Time,
Visibility
Of process
intuition
-
poor
intuition
Analysis
Stage 3: resolution
‘pure’ scientific
experiment
+
good
System aided
judgement
Task
Structure
Peer aided
judgement
Time,
Visibility
Of process
intuition
-
poor
intuition
Analysis
So what does all this mean?
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One size does not fit all and EB decision elements
present in many decisions
Structuring decisions moves people along the continuum
(All things being equal), expertise AND decision
knowledge a powerful combination
Implications for future research
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Looking inside the ‘black box’ for given (and common) tasks
Interventions