Nurses use of research information in clinical decision making Dr Carl Thompson Centre for Evidence Based Nursing Medical Research Council Department of Health

I want to talk to you today about the role of information (and especially research based information) in clinical decision making by nurses in the UK. Because 40 years of cognitive psychology tells me that you will only retain the first 3 minutes of this paper, I want to provide you with the take home message now: We need to be much more sophisticated in the ways in which we think about getting research knowledge into clinical decision making and that the 10 most common assumptions made by practice developers, educators and policy makers with regard to the provision of information for nurses are at best questionable and at worst downright unhelpful. I will argue that there is real potential for evidence based decision making amongst nurses but not in the way we currently try and make it happen. By an evidence based decision I mean a choice in which the nurse assigns weight to research information in the context of what the patient wants, the resources that are available and the expertise associated with the clinician. I also want what I say to be based on something other than my opinion so messages are based primarily on two real life studies. [next slide]

The studies Subjects: health visitors, practice nurses, district nurses, nurse practitioners, acute surgical, medical and coronary care nurses. Mixed method, multi-site case study design, 3 geographical areas over one year (1999-2000; 2001-2) In depth interviews (n=180) Observation data (600 hours) Q methodological statistical modelling (n=224) Local information resource audit (circa 1500 source documents) sampling frame (Thompson 1999), between method & subject triangulation; multi-rater Kappa In essence both studies were concerned with the instrumental use of information in practice and exploring what nurses actually did rather than simply what they said they did. Serious flaws with self report literature (low response rates, small sample sizes and temporal irrelevance) most importantly those studies which have examined information use in real time suggest that people overestimate those information sources that they perceive they should be using. We also wanted to model the shared perceptions of individuals in the hope that we might better be able to make use of those techniques for increasing the weight of research evidence in decision making by targeting those might likely to be receptive to different information formats and strategies for change and support.

Information use in decision making context Uncertainty is inescapable Decision making is often ‘missing link’ in models of research utilisation Adding value to what we know Decisions affect the ways we think and the knowledge required Expertise is not enough WE NEED TO KNOW MORE ABOUT DECISION TASKS AND RESPONSES OF NURSES Why focus on information use in the context of decision making? Healthcare is about decision making and decision making in healthcare is made under conditions of irreducible uncertainty. What we know about research utilisation (or rather the lack of it) can be added to by understanding that decision making is a central component of information use. It is both a key context for information need recognition, seeking and eventual use and also a driver for the same. Decisions affect the way we view information and knowing something about decisions helps us develop ways of providing information that are fit for the purpose of reducing uncertainty. Finally, this provision of information is crucial if we are to improve the quality and safety of health service provision.

Adverse events and errors 11% of admissions 850,000 adverse events deaths & permanent disability Between 7 and 8.4 additional bed days per adverse event 10% of adverse events have some kind of error at their core. Errors (as Sir James Reasons work has illustrated) represent mistakes in the application of intentions. Intentions involve planning which in turn requires information. Clearly with somewhere in the region of 85’000 mistakes in the planning of healthcare delivery per year then better information is required. The problem is that healthcare professionals are not great and handling the information they are presented with. NPSA 2002

This graph represents the variability amongst one group of newly qualified staff nurses undertaking a critical care CPD module. It represents the utility that a single clinical piece of information (the glasgow coma score) has for the judgement of whether a patient is in shock or not, each column is a different nurse. What you can see is that an equivocal GCS leads to nurses extracting positive and negative utility from the information – that’s great. The problem is that the nurses also incorrectly weight the value of a normal and abnormal GCS when making the judgement. A judgement which is likely to inform the decision to intervene – with all the costs and potential for harm that interventions in healthcare entail. So information use and decision making are at the heart of new professional roles, patient safety and most of all evidence based practice and yet as human beings we are prone to systematic and predictable errors.

What do we know? Decision based uncertainty finite Rx, Dx, communicating risks and benefits, prevention, referral, targeting, timing, SDO, information seeking One choice every 10 minutes in acute care No escaping the exercising of judgement and decisions (making a difference) It’s a challenging agenda but there is some good news: Finite range of uncertainties to be addressed by information However, opportunities for information response to needs arising from decisions are limited. Moreover, the need to actually be a decision maker in clinical practice is not going away.

The questions nurses ask…. What percentage of Diabetics taking Viagra find it effective and how does this compare to non-diabetics taking the drug? How long should a patient continue to take a B-Blocker for post MI? What is the evidence to suggest MMR is a safe vaccine? What are the benefits of Breast feeding a child after the first year of life? What is the most effective way to treat cracked nipples? What is the most appropriate pain relief regime for a terminally ill patient with bone pain? Researchers such as david covell, john ely, gorman and helfin, and keith Cogdill in examining the information needs of healthcare professional have used the device of getting clinicians to express their clinical uncertainty as a clinical question. These questions are illuminating for a variety of reasons: First, they represent a start point for commissioning relevant research (in fact the Health Technology Assessment process is already structured along these lines). Second, they allow the estimation of whether or not the core uncertainties faced by clinicians can actually be addressed using existing research designs. When we asked nurses to express their uncertainties what emerged was the fact that most questions nurses needed answers to were around whether what they are considering doing will achieve the outcomes they want, who should receive scarce resources based on likely benefit, what works in terms of preventative activity and how safe are treatments and nursing interventions. In primary care this commonality was extended to questions around forming diagnoses and prognoses. The bottom line is that these kinds of questions and assoicated uncertainty are ideally addressed by research evidence from Sreviews, RCTs and gold standard diagnostic studies. [next slide]

The information response 270 hours of observation ‘external’ resources used: 19/115 patients (district nurses); 57/224 patients (practice nurses and nurse practitioners); 15/55 patients (health visitors). 75%of these for pharmaceutical information needs. 85% of ‘external sources’ other colleagues or PCT members otherwise BNF (x2 on-line) You might assume that this relationship would lead to the widespread consumption of information then…. You would be wrong.

Information use Access and usefulness – human sources overwhelmingly accessible and most useful Barriers the need to bridge the skills and knowledge gap using information format to maximise limited opportunities for consumption limited access in the context of limited time time (caveat) HV 24 minute consultations, PNs 5 mins, acute care nurses <5 mins and not consultation based; dedicated nature of information seeking; opportunity costs) The overwhelming characteristics of the information seeking response to the challenges faced were: SLIDE The study acts as a way of grounding some of the normative assumptions that appear to characterise the current NHS information provision climate – there are ten of them. [slide]

one: only objective information is valuable Normatively – possibly Descriptively - untrue The study findings suggest that nurses have a strong reliance on the subjectively mediated information provided by others in clinical practice, to the extent that objectivity comes second place to a subjectively defined sense of ‘trust’ or credibility in the information source. The role of knowledgeable colleagues in providing contextualised information was heralded as a key advantage of the sources used. As with other aspects of decision making and task accomplishment in life, individuals tended towards satisfactory information solutions as opposed to the optimal (Simon H 1992).

Two:more information is better Problem is making sense of existing information rather than adding to it. Increasing the flow of info as a route to knowledgeable doers is not the answer Again, the results of our study indicate that simply increasing the flow of information to clinicians may not always result in more informed individuals – or ‘knowledgeable doers’ (Department of Health 1999). It was clear that for many nurses there were relatively few problems getting enough information. The problem for most nurses was interpreting and understanding the information that already exists – an internal, rather than external, locus of control (Case D 2002).

Three: objective information can be transmitted out of context Nurses reject ‘acontextual’ information sources in favour of context-rich advice Lack the appraisal skills to inject context into information Nurses apparent rejection of formal, acontextualied, information in favour of human sources with the ability to transmit information in context suggests that efforts to simply transmit information (and rely on nurses to transform it into knowledge) may be misguided. If clinicians are unable to understand formal, codified information in the form of research studies or systematic reviews then this injection of context is missing and the information will ultimately carry less weight than that provided by human sources; who have the ability to place the information directly in context of the decision faced.

Four: information can only be acquired from formal sources Information is ‘differences that makes a difference’ (Bateson 1979) Differences that made a difference (with the exception of drug-reference material) are informally located As (Case D 2002) highlights, this assumption – often made by those keen to foster information use - flies in the face of reality. Individuals in this study rarely used formal sources, and when employed, they tended to be for very specific decision tasks (pharmaceutical enquiry, continuing professional development assignments or education).

Five: relevant information exists for every need Nurses don’t recognise (or cannot verbalise) information needs Satisficing Nurses (like doctors) may acquire [over] confidence quickly (Urquhart 1999). Whilst it may be true that existing information may go some way towards meeting clearly articulated needs, our results indicate that recognising and expressing such needs is not always easy. Moreover, the tendency for ‘satisficing’ in information acquisition means that relevant informal (rather than optimal and formal) information provided by human sources is often enough to sate the information seeker.   A further reason why nurses (like physicians) may not go beyond the easily available (physically and intellectually) is that clinicians are overconfident in their knowledge use. (Urquhart C 1999) suggests that doctors develop confidence in the knowledge applied to their patients in as little as two similar clinical cases. The possibility exists then that uncertainty in clinical decision making in nurses can be extinguished with very little practical experience (Case D 2002): 247.

Six: every information need situation has a solution Information seeking = transforming need into workable format unfitness for purpose = negative feedback The formal information solutions available to clinicians (such as medical libraries, on-line databases, or personal information collections) involve the clinician having to transform their clinical dilemma into a form suitable for available resources. Indeed, the formulation of the focused clinical question is a key part of the evidence based decision making process. Results are almost always provided, but the discrepancy between what the nurse actually needs - but may not be able to verbalise - and what is provided may mean that the results end up reinforcing negative perceptions of information and a consequent judgement of perceived lack of usefulness. Nurses in the study often associated formal research based information with a lack of saliency, conflict with pre-existing beliefs (or alternatively only being receptive to information which ‘fitted’ pre existing beliefs) and time consuming search strategies often with poor payback for the effort expended.

Seven: information can always be made accessible Physical sense = yes Intellectual/cognitive = no Again, this assumption can only be met when information needs are clear and well articulated. Our attempt to construct a typology of clinical decisions faced by nurses represents a start-point for adapting information sources to the needs of nurses. However, this typology still fails to address the ‘complexity’ of nurses perceived needs. Contextual factors such as implied response time, case mix, stakeholder values and beliefs amongst others are still missing – and yet are important influences on information seeking behaviour (Case D 2002) (Yates JF et al. 2003).

Nurses functional units = colleague advice, ideas and consultation Eight: functional units of information sources fit the needs of individuals EBN functional units = systems, synopses, syntheses and studies (Haynes 2001) Nurses functional units = colleague advice, ideas and consultation Information resources define themselves - in part - by their units of information storage. For example, libraries are defined by books, journals and on-line facilities. The functional units of information most used in nurse decision making are colleague advice, ideas and consultation. Most efforts at encouraging evidence based practice rely on encouraging nurses to adapt their information needs to the functional units of evidence based practice. Even where considerable efforts has been made to adapt the sources to needs – c.f. Haynes’ 4S solution: systems, synopses, syntheses and studies (Haynes RB 2001). The study results demonstrate both the gap between what is available and what is used, and the relative lack of skills and abilities to make use of the functional units of evidence based practice.

Nine: time and space ignored + Time, Visibility Of process - good Task Structure poor ‘pure’ scientific experiment System aided judgement Peer aided judgement intuition (cf. Hammond, Hamm, Dowie 1963-2002) intuition Analysis

Defensiveness and conflict We simply do not know! Ten: easy conflict free connections between external information and internal reality Defensiveness and conflict We simply do not know! This assumption works if we assume that nurses and other clinicians are able to link external information to their particular decision challenge without invoking a sense of internal conflict. In fact, we know very little about how nurses and other clinicians make connections between information and clinical decision making over time and in real decision making situations. That research which exists relies primarily on self-report or think-aloud methods (Bucknall T & Thomas S 1997;Gerdtz M & Bucknall TK 2001;Hallett CE et al. 2000), with the consequence that participants may be more inclined to say what the researcher would like to hear. Researchers are beginning to use techniques such as Social Judgement Analysis to begin to examine the weighting assigned to information in decision making (Harries 2002) and such techniques have been used to good effect in medicine (Wigton RS, Hoellerich VL, & Kashinath DP 1986). There are few such studies in nursing and the method relies on experimental manipulation of information (albeit derived from real-life deconstructed decision or judgement tasks). Nurses in the study often revealed that they knew they should be using formal information in their decision making processes but were also aware that they were very often not. This awareness generated feelings of guilt, some defensiveness and a sense of internal conflict in some clinicians.

conclusion “Ask not what information does to people but what people do to information” (Brenda Dervin 1976) Distinguish between information and knowledge use Recognise that (micro level) information application is a social activity and complex