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 That the context for EBN means that information (no matter how good the quality) is never enough 10 information myths that illustrate the reality of EB decision making 10 information myths that illustrate the reality of EB decision making Nurses vary enormously in their handling of even experientially-generated, relevant, knowledge – so what hope for research info. Nurses vary enormously in their handling of even experientially-generated, relevant, knowledge – so what hope for research info. That using evidence involves costs, benefits, trade-offs: it’s a PURCHASING decision made by members of a COMMUNITY (of practice) That using evidence involves costs, benefits, trade-offs: it’s a PURCHASING decision made by members of a COMMUNITY (of practice)

Patient Safety and decision making 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 interviews 200 in depth interviews 400 hours observation (decision making and information use in action) 400 hours observation (decision making and information use in action) 4000 documents audited 4000 documents audited Q methodological modelling (242 nurses) Q methodological modelling (242 nurses) Social judgement modelling (critical care and community nurses, 2003 – pres) Social judgement modelling (critical care and community nurses, 2003 – pres) “Think aloud” and video “Think aloud” and video context (research ) Thompson et al. 1999, 2000, , 2004, in press

… if X then Y and Z context (information to knowledge)

Repetition Activity Behaviour Practice Training Observation experience Learning Behavioural trends, Changes and Incremental modification Hilguard, Marquis 1961 Context (learning) Observable…unobservable…observable

Typology* of decision related uncertainty Intervention/effectiveness Intervention/effectiveness Targeting Targeting Timing Timing Prevention Prevention Referral Referral Communication (risks and benefits) Communication (risks and benefits) SDO SDO Assessment Assessment Dx Dx Information seeking Information seeking Experiential, understanding or hermeneutic Experiential, understanding or hermeneutic Thompson et al. 2000, , 2004; McCaughan et al * Kappa 0.82 Thompson et al. IJNS 2004

The 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 members otherwise BNF (x2 on-line) 85% of ‘external sources’ other colleagues or PCO members otherwise BNF (x2 on-line) 180 hours of acute care observation (circa 1080 decisions) only 2 forms of text based information used (local guidelines x 4 and BNF x 50) 180 hours of acute care observation (circa 1080 decisions) only 2 forms of text based information used (local guidelines x 4 and BNF x 50)

The 10 information for nurse decision making ‘myths’  Only objective information is valuable  More information is always better  Information can be transmitted without context  Information can only be acquired from formal sources  Relevant information exists for every need  Every information need has a solution  Information can always be made accessible  Functional units of information fit the functional units of individuals  Time and space don’t matter  External information and internal reality can be united without conflict

only objective information is valuable Normatively – possibly Normatively – possibly Descriptively - untrue Descriptively - untrue

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

objective information can be transmitted out of context Nurses reject ‘acontextual’ information sources in favour of context-rich advice Nurses reject ‘acontextual’ information sources in favour of context-rich advice Lack the appraisal skills to inject context into information Lack the appraisal skills to inject context into information

information can only be acquired from formal sources Information is ‘differences that makes a difference’ (Bateson 1979) Information is ‘differences that makes a difference’ (Bateson 1979) Differences that made a difference (with the exception of drug-reference material) are informally located Differences that made a difference (with the exception of drug-reference material) are informally located

relevant information exists for every need Nurses don’t recognise (or cannot verbalise) information needs Nurses don’t recognise (or cannot verbalise) information needs Satisficing Satisficing [over] confidence quickly acquired (Urquhart 1999). [over] confidence quickly acquired (Urquhart 1999).

every information need situation has a solution Information seeking = transforming need into workable format Information seeking = transforming need into workable format unfitness for purpose = negative feedback unfitness for purpose = negative feedback

information can always be made accessible Physical sense = yes Physical sense = yes Intellectual/cognitive = no Intellectual/cognitive = no

functional units of information sources fit the needs of individuals EBN functional units = systems, synopses, syntheses and studies (Haynes 2001) EBN functional units = systems, synopses, syntheses and studies (Haynes 2001) Nurses functional units = colleague advice, ideas and consultation Nurses functional units = colleague advice, ideas and consultation

intuition ‘pure’ scientific experiment Peer aided judgement System aided judgement good Task Structure poor + Time, Visibility Of process - intuitionAnalysis (cf. Hammond, Hamm, Dowie ) time and space ignored Mode of decision making

conflict free connections between external information and internal reality Defensiveness and conflict Defensiveness and conflict We simply do not know! We simply do not know!

What is SJT? ‘ecology’

Intra-group variation

Information utility

High school Collegegraduate

Felt need Pre-purchase activity Purchase decisionUse 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

knowledge Lives in the human act of knowing Lives in the human act of knowing Is tacit as well as explicit Is tacit as well as explicit Social as well as individual Social as well as individual Is dynamic Is dynamic knowledge