Why providing information for Why providing information for evidence based decision making evidence based decision making

by nurses is a bad idea…by nurses is a bad idea…

Carl ThompsonUK Department of Health, Senior Research Fellow

What is he talking about…?What is he talking about…? That the context for EBN means that information (no That the context for EBN means that information (no

matter how good the quality) is never enoughmatter how good the quality) is never enough

10 information myths that illustrate the reality of EB 10 information myths that illustrate the reality of EB decision makingdecision making

Nurses vary enormously in their handling of even Nurses vary enormously in their handling of even experientially-generated, relevant, knowledge – so experientially-generated, relevant, knowledge – so what hope for research info.what hope for research info.

That using evidence involves costs, benefits, trade-That using evidence involves costs, benefits, trade-offs: it’s a PURCHASING decision made by members of offs: it’s a PURCHASING decision made by members of a COMMUNITY (of practice)a COMMUNITY (of practice)

Patient Safety and decision

making

Evidence from

research

Clinical

expertise

Patient

preferences

Available resources

Evidence

Based Decision

context (errors, information, combination and unknowns)

2 multi site case studies (1997 – 2002)2 multi site case studies (1997 – 2002) theoretically sampled theoretically sampled 200 in depth interviews200 in depth interviews 400 hours observation (decision making and 400 hours observation (decision making and

information use in action) information use in action) 4000 documents audited4000 documents audited Q methodological modelling (242 nurses)Q methodological modelling (242 nurses)

Social judgement modelling (critical care Social judgement modelling (critical care and community nurses, 2003 – pres) and community nurses, 2003 – pres) ““Think aloud” and videoThink aloud” and video

context (research )

Thompson et al. 1999, 2000, 20012002, 2004, in press

10001000110011010… if X then Y and Z

context (information to knowledge)

RepetitionActivity

BehaviourPracticeTraining

Observationexperience

Learning

Behavioural trends,Changes and Incremental modification

Hilguard, Marquis 1961

Context (learning)

Observable…unobservable…observable

Typology* of decision related Typology* of decision related uncertaintyuncertainty

Intervention/effectivenessIntervention/effectiveness Targeting Targeting Timing Timing PreventionPrevention

ReferralReferral Communication (risks and benefits)Communication (risks and benefits) SDOSDO AssessmentAssessment DxDx Information seekingInformation seeking Experiential, understanding or hermeneuticExperiential, understanding or hermeneutic

Thompson et al. 2000, 20012002, 2004; McCaughan et al. 2002

* Kappa 0.82 Thompson et al. IJNS 2004

The information responseThe information response 270 hours of PCO observation ‘external’ resources used: 270 hours of PCO observation ‘external’ resources used:

19/115 patients (district nurses); 19/115 patients (district nurses); 57/224 patients (practice nurses and nurse practitioners); 57/224 patients (practice nurses and nurse practitioners); 15/55 patients (health visitors). 15/55 patients (health visitors).

75% of these for pharmaceutical information needs.75% of these for pharmaceutical information needs.

85% of ‘external sources’ other colleagues or PCO 85% of ‘external sources’ other colleagues or PCO members otherwise BNF (x2 on-line) members otherwise BNF (x2 on-line)

180 hours of acute care observation (circa 1080 180 hours of acute care observation (circa 1080 decisions) only 2 forms of text based information used decisions) only 2 forms of text based information used (local guidelines x 4 and BNF x 50)(local guidelines x 4 and BNF x 50)

The 10 information for nurse The 10 information for nurse decision making ‘myths’decision making ‘myths’

Only objective information is valuable Only objective information is valuable More information is always better More information is always better Information can be transmitted without context Information can be transmitted without context Information can only be acquired from formal sourcesInformation can only be acquired from formal sources Relevant information exists for every needRelevant information exists for every need Every information need has a solution Every information need has a solution Information can always be made accessible Information can always be made accessible Functional units of information fit the functional units of Functional units of information fit the functional units of

individuals individuals Time and space don’t matterTime and space don’t matter External information and internal reality can be united External information and internal reality can be united

without conflictwithout conflict

only objective information is only objective information is valuablevaluable

Normatively – possiblyNormatively – possibly

Descriptively - untrueDescriptively - untrue

more information is bettermore information is better

Problem is making Problem is making sense of existing sense of existing information rather information rather than adding to it.than adding to it.

objective information can be objective information can be transmitted out of contexttransmitted out of context

Nurses reject ‘acontextual’ Nurses reject ‘acontextual’ information sources in favour information sources in favour of context-rich adviceof context-rich advice

Lack the appraisal skills to Lack the appraisal skills to inject context into informationinject context into information

information can only be information can only be acquired from formal sourcesacquired from formal sources

Information is ‘differences that Information is ‘differences that makes a difference’ (Bateson 1979) makes a difference’ (Bateson 1979)

Differences that made a difference Differences that made a difference (with the exception of drug-(with the exception of drug-reference material) are informally reference material) are informally locatedlocated

relevant information exists for relevant information exists for every needevery need

Nurses don’t recognise (or cannot Nurses don’t recognise (or cannot verbalise) information needsverbalise) information needs

Satisficing Satisficing

[over] confidence quickly acquired [over] confidence quickly acquired (Urquhart 1999). (Urquhart 1999).

every information need situation every information need situation has a solutionhas a solution

Information seeking = Information seeking = transforming need into transforming need into workable formatworkable format

unfitness for purpose = unfitness for purpose = negative feedbacknegative feedback

information can always be made information can always be made accessibleaccessible

Physical sense = yesPhysical sense = yes

Intellectual/cognitive = noIntellectual/cognitive = no

functional units of information sources functional units of information sources fit the needs of individuals fit the needs of individuals

EBN functional units = systems, EBN functional units = systems, synopses, syntheses and studies synopses, syntheses and studies (Haynes 2001)(Haynes 2001)

Nurses functional units = Nurses functional units = colleague advice, ideas and colleague advice, ideas and consultationconsultation

intuition

‘pure’ scientific experiment

Peer aided judgement

System aided judgement

good

Task Structure

poor

+

Time,VisibilityOf process

-

intuition Analysis

(cf. Hammond, Hamm, Dowie 1963-2002)

time and space ignored

Mode of decision making

conflict free connections between external conflict free connections between external information and internal realityinformation and internal reality

Defensiveness and conflictDefensiveness and conflict

We simply do not know!We simply do not know!

What is SJT?What is SJT?

‘ecology’

1.002.00

3.004.00

5.006.00

7.008.00

9.0010.00

11.0012.00

13.0014.00

15.0016.00

17.0018.00

19.0020.00

Scenario

0.00

25.00

50.00

75.00

100.00

scenario

20

19

18

17

16

15

14

13

12

11

10

9

8

7

6

5

4

3

2

1

%

100

90

80

70

60

50

40

30

20

10

0

shock

not in shock

Intra-group variationIntra-group variation

Importance (individual)

GCSurine outputO2respspulsesystolic BP

Impo

rtanc

e

60

50

40

30

20

10

0

Importance (group)

GCSurine outputO2respspulsesystolic BP

Impo

rtanc

e

30

20

10

0

Information utilityInformation utility

Summary Utilities

glasgow coma score

abnormalequivocalnormal

Utilit

y

.8

.6

.4

.2

-.0

-.2

-.4

-.6

Individual Subject Utilities

glasgow coma score

abnormalequivocalnormal

Utilit

y

20

10

0

-10

-20

educational attainment

GC

S a

bn

orm

al

12

9

6

3

0

-3

-6

-9

-12High school

College

graduate

Felt

need

Pre-purchase

activity

Purchase decision Use behaviour Post purchase

feelings

Info need

recognition

Info search

behaviour

Evaluation of

Info alternatives

Use behaviour Post use

evaluation

Case 2002Kotler 1967;

Purchasing behaviour

Information behaviour

knowledgeknowledge

Lives in the human act of knowingLives in the human act of knowing

Is tacit as well as explicitIs tacit as well as explicit

Social as well as individualSocial as well as individual

Is dynamicIs dynamic

knowledge