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Why providing information for evidence based decision making by nurses is a bad idea…. Carl Thompson UK Department of Health, Senior Research Fellow. What is he talking about…?. That the context for EBN means that information (no matter how good the quality) is never enough - PowerPoint PPT Presentation
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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