Decision-making in a multi-disciplinary changing healthcare environment: Experiences of Australian Bush Nurses. Mollie Burley Centre for Multidiscipline Studies Monash University School of Rural Health Moe, Victoria, Australia

2 Presentation overview. Bush nursing: –Context & role Decision-making: –Types of knowledge & knowing –Theories –Bush nurses lived experiences Blurring the boundaries Findings

3 AUSTRALIA

4 Brisbane Sydney Hobart Adelaide Canberra Melbourne Victoria Darwin Perth

5 East Gippsland VICTORIA AUSTRALIA Bairnsdale Melbourne

6 Cann Rv EAST GIPPSLAND VICTORIA AUS Swifts CK Buchan Dargo Gelantipy Bairnsdale Moe

7 Bush Nursing Context: BNC Kms: Regional H/S Time: Regional H/S Time Major Referral H/S Major Metro: Specialists A751.0 hr2.3 hrs4.0 hrs B hrs3.15 hrs4.45 hrs C hrs3.0 hrs5.3 hrs D hrs3.10 hrs5.4 hrs E hrs3.5 hrs5.0 hrs Bush Nursing Context -1:

8 Bush Nursing Context - 2: Advanced practitioners working alone in small clinics Primary healthcare – populations <500 Telephone access - advice & support Local resources: –volunteer ambulance officers –Police & State Emergency Service backup Complex decision-making required

9 Decision-making. Complexity: Uncertain & unstable healthcare environments Rapid pace of change More informed consumers Higher expectations Higher client acuity Demands for efficiency, effectiveness and rationale for decision-making

10 Majority of nursing decisions: Intervention: –Modify the situation Communication: –Give or receive information Evaluation: –Review/evaluate client data –Determine current health status

11 Key decision theories. Systematic or analytical – information processing theory –Theoretical / empirical evidence ie: transparent –Hypothesis confirmed or refuted –Decision system into short & long term memory –Bayesian logic Intuitive – humanistic theory –Lack of consensus about intuition –Intuition/expertise ie: invisible –Context/domain-specific –Heuristics rules of thumb

12 Cognitive Continuum Theory. Middle ground between Intuition and Analysis Neither analytical nor intuitive framework explains practice decisions Involves modes of cognition determined by: –Structure of task –Time available for decision –Number of information cues

13 Well structured Task Characteristics Ill structured Scientific experiment (Mode 1) High Potential for manipulation; visibility; time required Low Controlled trials (Mode 2) Quasi- experimental (Mode 3) System-aided judgment (Mode 4) Peer-aided judgment (Mode 5) Intuitive judgment (Mode 6) INTUITION Mode of cognition ANALYSIS Short time/ Time frame & control Long time/ Low control High control Cognitive Continuum Theory: 6 models of enquiry/practice, adapted from Hammond HARBISON, J. (2001) Clinical decision making in nursing: theoretical perspectives & their relevance to practice. Journal of Advanced Nursing, 35,

14 Types of knowledge.

15 Propositional knowledge: knowing that. Scientific research to theory Critical thinking: Hypothesis-deductive reasoning Generalised findings Higher status knowledge Heuristics – pattern recognition & rules of thumb Objective knowledge of the field Public knowledge of the external world

16 Professional Craft Knowledge: knowing how Embedded in practice & creates new knowledge Discipline-specific clinical knowledge Interpretive models eg: Benner (1984) –Emphasis on social or human services –Client-centered care Iceberg theory –1/10 th visible –9/10 ths invisible Knowledge – general & specific

17 Personal Experience: knowing how Emancipatory & imaginative knowledge Clinician engaged in the interaction Result of personal experience & reflection Unique frame of reference of self Understand complex human desires Feelings, purposefulness, interpersonal, emotional and spiritual

18 Gathering decision-making data: Integration and re-analysis of data collected for original study Literature review Lived experiences of bush nurses – vignettes –Positive & negative stories from all aspects of clinical role Healthcare professionals survey –Interaction/s with BN –Quality of BN decisions

19 Lived experiences of BNs. In a Semi-structured survey bush nurses: Reflected on events that had an impact on them/their practice Classified experience as positive or negative [No limit on number of responses] Documented the event 29 responses received –15 positive related mainly to clinical –14 negative related mainly to relationships Child burns example

20 Multi-disciplinary collaboration - 1. Questionnaire 65 distributed, 38 returned -58.5% return rate 14 Doctors, 11 Nurses, 2 Allied Health & 2 other disciplines Doctors: –11 general practitioners – 3 specialists Nurses: –4 Womens health –3 Diabetes –1 each from Mental health, community, Drug and Alcohol & Immunization

21 Multi-disciplinary collaboration - 2. Allied health: –Pharmacist –Psychologist Other disciplines: –4 Complementary therapists –4 Social welfare –1 Ambulance –1 Pathology –1 State Emergency Service

22 Reasons for collaboration. CATEGORYTOTALDURING HRS AFTER HRS Clinical advice25196 Follow-up15 0 Emergency advice1046 Referral 770 Feedback 761 Peer support660 Other17134

23 Blurring the boundaries: Advanced primary healthcare practitioners Skills in Advanced health assessment, Mental Health First-Aid & Counselling Liaise with health professionals & implement treatment/care Shared care with a range of clinicians Multi-disciplinary team participant Emergency & trauma care

24 Conclusion; Bush nurses are ….. Advanced practitioners Negotiate boundaries - multi-disciplinary team Effective decisions Range of decision-making models Difficulty articulating: –decisions & –contribution to care Recognition –valued members of multi- disciplinary team

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26 Contact details: Mollie Burley Center for Multi-disciplinary Studies Monash University School of Rural Health PO Box 973 MOE Victoria Australia