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

methods Subjects: health visitors, practice nurses, district nurses, nurse practitioners Subjects: health visitors, practice nurses, district nurses, nurse practitioners Mixed method, multi-site case study design, 3 geographical areas over one year (2001-2) Mixed method, multi-site case study design, 3 geographical areas over one year (2001-2) In depth interviews (n=82) In depth interviews (n=82) Observation data (270 hours) Observation data (270 hours) Q methodological statistical modelling (n=120) Q methodological statistical modelling (n=120) Local information resource audit (circa 1000 sources) Local information resource audit (circa 1000 sources) Rigour: explicit purposive sampling frame; between method & subject triangulation; multi-rater Kappa for descriptive coding tasks Rigour: explicit purposive sampling frame; between method & subject triangulation; multi-rater Kappa for descriptive coding tasks

Why information use in decision making context? Finite range of uncertainties (coming next…) Finite range of uncertainties (coming next…) Decision making is often ‘missing link’ in models of research utilisation Decision making is often ‘missing link’ in models of research utilisation Adding value to what we know Adding value to what we know Decisions affect the ways we think and the knowledge required Decisions affect the ways we think and the knowledge required Expertise is not enough Expertise is not enough WE NEED TO KNOW MORE ABOUT DECISION TASKS AND RESPONSES OF NURSES

intuition ‘pure’ scientific experiment Peer aided judgement System aided judgement good Task Structure poor + Time, Visibility Of process - intuitionAnalysis Cognitive continuum (cf. Hammond, Hamm, Dowie )

Decision space in the real world? Assume limited time Assume limited time Increasing need for visibility in decision making Increasing need for visibility in decision making Task structure is vital to understanding the mechanism for inducing cognition 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 Understand task structure – possibility of inducing ways of thinking and different kinds of knowledge use

SHARED DECISION MAKING VALUES ROLE CONFLICT, GP WISHES COST NEED FOR VISIBILITY IN DECISION REJECTION OF EXPERTISE PATIENT REJECTION OF EXPERTISE CNS WOUND FORMULARY COST DOWN TO WHAT I’VE USED OVER THE YEARS SEEING IS BELIEVING AND EXPERIMENTATION Investigations: urine, FBC, ESR, urea and electrolytes, blood glucose, swab (if appropriate) Background information History: how and when ulcer started; current treatment; pain… etc General medical condition: diabetic? RA; anaemic?… etc Other health information: smoker? Mobility? Medication?…etc general condition: well? Pulse, BP, weight Leg exam: oedema, temperature; ankle and calf circumference… Ulcer: size, odour, slough, exudates? Doppler ABPI Compliance? ARTICLES PHYSIOLOGY DAILY VISITS PATIENT INFORMATION COLLEAGUE’S ‘EXPERIMENTS’

intuition ‘pure’ scientific experiment Peer aided judgement System aided judgement good Task Structure poor + Time, Visibility Of process - intuitionAnalysis Stage 1: assessment

intuition ‘pure’ scientific experiment Peer aided judgement System aided judgement good Task Structure poor + Time, Visibility Of process - intuitionAnalysis Stage 2: conflict

intuition ‘pure’ scientific experiment Peer aided judgement System aided judgement good Task Structure poor + Time, Visibility Of process - intuitionAnalysis Stage 3: resolution

So what does all this mean? One size does not fit all and EB decision elements present in many decisions One size does not fit all and EB decision elements present in many decisions Structuring decisions moves people along the continuum Structuring decisions moves people along the continuum (All things being equal), expertise AND decision knowledge a powerful combination (All things being equal), expertise AND decision knowledge a powerful combination Implications for future research Implications for future research Looking inside the ‘black box’ for given (and common) tasks Looking inside the ‘black box’ for given (and common) tasks Interventions Interventions