How do nurses use new technologies to inform decision making?

Project Aims Identify areas of practice in the NHS where new decision support technologies have been introduced or where their introduction is imminent Explore how new technologies are used to inform decision making in practice and the potential effect these may have on the care delivery process and patient outcomes Examine the role of education and training in the introduction of new technologies in practice.

Methods Systematic review Survey of NHS Trusts Secondary analysis of existing data sets Case study

Systematic Review Update

Comparisons 1.Nurses using CDSS v. nurses not using CDSS 2.Nurses using CDSS v. other health professionals not using CDSS 3.Health professionals using CDSS v. health professionals not using CDSS, where nurses were a subgroup of the participants

Articles identified through searching of reference lists and contacting authors and experts in the field, retrieved in full text for screening (n=49) Articles identified through database searching and screened (n=6885) Articles included in review (n=20) Potentially relevant articles retrieved in full text for screening using full set of inclusion criteria (n=333) Excluded (n=362): Intervention not CDSS (n=119) Not original research article (n=111) CDSS not used by nurses (n=87) Not RCT/CBA/CCT/ITS (n=41) Intervention not evaluated in real clinical setting (n=2) Did not provide measurable outcomes (n=2) Excluded (n=6552): Duplicates (n=15) Not about CDSS (n=5664) Not about nurses (n=304) Not original research article (n=569)

Comparison 1 3 studies –Anticoagulation management –Triage (NHS Direct vs. practice nurse) –Glucose regulation in ICU Performance outcomes: 1 study suggests CDSS to be beneficial, 1 study suggests CDSS to be detrimental Patient outcomes: 2 studies support hypothesis of no difference

Comparison 2 5 studies –3 studies of anticoagulation management –2 studies of triage: 1 for out-of-hours care, 1 for same day appointment requests Performance outcomes: 3 studies suggest CDSS to be beneficial Patient outcomes: 4 studies suggest CDSS to show some benefit, 1 study suggests CDSS to be detrimental

Currently… Narrative summary Visual and statistical analyses

Survey Update

Aims of the Survey Provide data on the progress of implementing NPfIT in NHS Trusts Identify current uses of CDSS by nurses in NHS trusts

Method Survey in 2 parts Part 1: Implementation of NPfIT & use of CDSS by nurses Part 2: A more detailed picutre of the nature & purpose of the CDSS being used

Pilot Study 2 SHA’s N = 29 (PCT 15; AT 10; MHT 4) Response rate = 59% 19 Part 2’s returned *35% Trusts reported no CDSS at all *Varied settings for CDSS use *26% of CDSS provides an automatic decision

The Survey 50% of each type of NHS Trust in England N = 272 plus 4 additional Trusts Chief Executive letters

Response Rate Randomised Trusts: 276 Trusts Refused: 74 Surveys sent out: 123 Surveys Returned: 64 Awaiting Response: 59

How Do Nurses Use New Technologies to Inform Decision Making ? Secondary Analysis Update January 2006

Background Secondary analysis of data from two previous studies that have addressed aspects of the use of new technologies by nurses (i)DH funded evaluation of the Exemplar Programme for integrated out of hours care (ii)MRC-funded project looking at nurses’ use of research information in decision making in primary care.

(i) Exemplar Evaluation data Semi-structured interviews with 88 staff in 4 ‘Exemplars’ including nurses, nurse managers, general practitioners, other clinicians, call handlers, call centre managers and commissioners (Nov 2001to Jan 2002) Primary focus was their experience of planning and implementing a new model of integrated out-of-hours care Data refer to the use of NHS CAS: direct experiences of nurses using decision support, together with the observations of other staff of the impact of CDSS on the care of patients and on how staff practice.

The patient makes a single call, forwarded automatically with an explanatory message NHS Direct Call Management and Nurse Triage Ambulance Accident & Emergency GP on the telephone GP or Nurse Face-to-Face Consultation In Primary Care Centre or Walk-in Centre In A&E Primary Care Centre At home Community Nursing Information Service or health information Self care Call back Patient or call centre initiated Advice GP later next day or routine appointment (direct booking to GP system) Mental Health Out-of-Hours Team Out-of-Hours Dental Service Social Services or Home Care Team Pharmacy Advice The Integrated Model Of Out- Of-Hours Care

(i) Exemplar Evaluation data 53 selected for inclusion in the secondary analysis. ‘Framework analysis’ method: familiarisation, identifying a thematic framework, indexing, charting, mapping and interpretation. 45 interview transcripts indexed so far: all text relevant to each item in the index entered into a matrix in Excel.

Reference to core questions in the ‘New Technologies’ Project: How does unsupported decision making differ from nurse decision making when a CDSS (computerised decision support system) is in use? What is the evidence that the outcomes of technology supported decisions are better then those of unsupported decisions? What kinds of education and training do nurses need to use decision technologies in practice?

(ii) Nurses’ use of research information in decision making in primary care. Data collected between November 2001 and September 2002 across three sites. Observations and interviews with practice nurses (approx. 30), district nurses (approx. 30), and health visitors (approx. 30). Field notes from approximately 120 hours of observations have been collected. Secondary analysis of this data is due to begin at the end of January 2006

Case study

Aims How unsupported decision making differs from decision making when CDSS is in use? What is the evidence that outcomes of technology supported decisions are better than those of unsupported decisions? What kinds of education and training do nurses need to use new technologies in practice? What are the characteristics of technology, organisation, individuals and decisions that are most likely to increase the use of new technolgies in the future?

Case site selection SAMPLE DECISION CONTEXT Type of setting Organisational culture Implementation methods Education and training DECISION TASK Type of decision Complexity DECISION MAKER Expertise Experience with technology Education and training TECHNOLOGY Mode of delivery of information User interface Purpose