the face of evidence in nurses’ clinical decision making. carl thompson, centre for evidence based...

The face of evidence in nurses’ clinical decision making.

Carl Thompson, Centre for Evidence Based Nursing, Department of Health Studies, University of York.

Research Questions…Do nurses see research information as useful?

How do nurses access research based information?

What stops them using research based info?

WHAT IS THE POTENTIAL FOR EBN?

Methodology…Mixed qualitative and quantitative case

site designPurposive sampling of cases (sites),

wards, individuals and practice130 interviews180 hours of observationQ methodological data on >100 people.

Q methodology… construction of a Q sample Q sorting Interpretation I): statistical Interpretation II): qualitative interpretation Conventional ‘r’ methodological

regression modelling.

decisions…decisions…

To err is human… Bounded rationality and satisficing means

failure Incomplete knowledge means failure Knowledge base itself means failure

(heuristics) Selectivity Availability Confirmation bias Hindsight bias Overconfidence

EBN can help! Converting clinical uncertainty to clinical

questions Helps frame problems The search process systematises the knowledge

gathering process Generates answers or at the least informed non-

decisions Appraisal and meta analysis help combat selective

overviewing Most of all it helps avoid the common scenario

of information overload…

But can nurses ask clinical questions based on the decisions they face…?

Tentatively yes… Asked nurses to reflect on a clinical decision

they had made and to convert this into a clinical question (few examples & no training)

Good results – all did it (although six chose examples!)

Significant minority (around 30%) conformed to the 3 or 4 part evidence based focussed clinical question format.

Intervention or effectiveness Which kind of mattress to nurse a frail elderly

man on who has been admitted with bowel obstruction

In patients who are elderly and inactive, and may require surgical intervention, which is the most suitable pressure relieving mattress to prevent complications i.e. pressure sores

Timing decisionsChoosing a time to commence asthma

education

 When to commence asthma education

on newly diagnosed asthmatics?

Communicating risks and benefitsA patient coming for a 1st dose of

chemotherapy asks the risks and side effects of that treatment

 How many patients receiving

chemotherapy will experience side effects and will the benefit of treatment outweigh the risks?

targetingAn elderly lady who is bed bound. Her

sacrum is starting to become red, she is able to move herself around the bed but is concerned about pressure sores.

 At what point would a special pressure

sore mattress or bed be brought into the management of this patient?

Organisation and service delivery?Choosing new pressure relieving

mattress for unit.

In a coronary care unit with no age limit admission criteria, which pressure relieving mattress system will prove to be most effective, durable and financially viable?

So far so good?Reasonable to hypothesise that given a

solid (and quickly acquired and reinforced) skill nurses could improve the ways in which they engage with research evidence?

Maybe, maybe not?

I do not seem to use research much to make my decisions. I feel that this is justified because I

am looking at the patient holistically. This is why the patient and family come before research. The first and most useful sources I felt were

experienced nurses, and particularly specialist nurses for this area if there were any. This is

because these nurses should be up to date with methods and will have tried them, rather than going on research which is sponsored by drug

companies, or for somebody’s degree etc.

barriers to research evidence use…

Q sample of 60 items (based on first level interpretative coding schema)

Open sample (not structured to ‘test’ or operationalise a particular theory)

Just four factors account for 37% of the variance associated with the individuals.

Lacks confidence could try harder…Accounts for most of the variance (12%) Problem is with the stuff we

(researchers) produceCauses conflicting feelings (want to be

doing the right thing but can’t?)Solutions? Product improvement and

core skills related?

Lacks confidence(ii) agree

Statistics put me off research (+5)

…too academic (+5) …too complicated (+5) …don’t have necessary

computer skills (+4) …no real confidence in

reading research Poor basic education No facilities… Other nurses are a block

on using research

disagree …best left to college

leavers (-5) …hasn’t resulted in

better decisions Culture not geared up for

using research More for manager than

practicing nurses Its unrealistic using

research information in clinical decisions as… not suited

Lacks confidence(ii) agree

Statistics put me off research (+5)

…too academic (+5) …too complicated (+5) …don’t have necessary

computer skills (+4) …no real confidence in

reading research Poor basic education No facilities… Other nurses are a block

on using research

disagree …best left to college

leavers (-5) …hasn’t resulted in

better decisions Culture not geared up for

using research More for manager than

practicing nurses Its unrealistic using

research information in clinical decisions as… not suited

Confident underachievers?Accounts for similar amount of variance

(10%) as previous factorNot afraid of research Broadly positive to research info

generallyOrganisational cultural barriers are

biggest obstacle

Confident underachievers (ii) Agree

Other nurses block using research

Facilities to help use research not based on site

Used in the past cost too much time and money

Don’t have the facilities R&D support structures

hinder rather than help Medics block research use Geographical specificity

and TIME!

disagree Too academic Not practice related Too wishy washy Uses complex

language Too complicated No motivation for

using research

Confident underachievers (ii) Agree

Other nurses block using research

Facilities to help use research not based on site

Used in the past cost too much time and money

Don’t have the facilities R&D support structures

hinder rather than help Medics block research use Geographical specificity

and TIME!

disagree Too academic Not practice related Too wishy washy Uses complex

language Too complicated No motivation for

using research

So how ‘exactly’ does it work? Third factor very similar to previous factor:

Confident Good basic educational preparation Differentiated by the degree of importance

attached to time they have adequate computer skills clinical credibility (read information if written by a nurse

and most authors not credible) Want more direction from research evidence. Existing policies were seen as unwieldy

The Challengers?Far too busyconfident in reading researchBut no motivation to use itPartly product related (stats and out of

date) Desire to have research built into

existing technologies.

What about accessibility… Q sample from sources quoted in interviews,

observed and audited. wound care case scenario. 3 factors = over half (54%) of the variance in the

sample. most accessible sources overwhelmingly human Inaccessibility associated with more ‘transparent’

resources and helpful technologies (online databases, internet, journals)

Accessibility… Most accessible

Clinical nurse specialists

Experienced colleagues

Link nurses Registrars &

Consultants (disputed!)

Least accessible Local medical/

nursing librarian Nursing directorates Home-based internet RCN direct Medline/CINAHL

Text-based technologies somewhere in the middle – but have to be developed by ‘locals’!

What’s useful…Four factors account for 56% of the

variance associated with the sorts.First two together account for 45% all the people who defined factor 2 did

so negatively in effect then a single factor that

accounts for 45% of the variance.

What’s useful…(ii) Most useful

clinical nurse specialists

link nurse previous experience ward manager/sister the patient or family local clinical

guidelines/protocols

Least useful textbook >10years media articles the internet (www) text book <10years product helplines journal club JAN research study BMJ research study

Questions…

Should we be questioning nursing’s evidence base?What does a ‘qualitative’ clinical

question look like?

Knowledge…fit for purpose?

0

200

400

600

800

1000

1200

82-84 85-88 89-92 93-98

qual

RCT

How best to close some of the contradictions highlighted:

CNSs and link nurses seen as useful and accessible but no organisational or structural power

Huge efforts on the part of Trusts with little discernible impact should we divert resources?

Would basic skills training make a difference?Question development based on

knowledge of decisions.Effective and efficient use of existing

resourcesTraining for uncertainty rather than

certainty?

Future?

•Is the picture similar in primary care?•Intervention studies to combat the skills and product-related problems•National educational strategy •Local and national developmental agenda