Can we ever make nursing decisions “evidence based”? Carl Thompson UK, Centre for Evidence Based Nursing

Evidence Based Decisions (cf. Dicenso, Cullum,Ciliska et al. 1998) “The consideration of relevant, valid, research evidence when making clinical and policy decisions in nursing” Research preferences Context (resources, expertise) Research preferences Context ( resources expertise)

The 5 Ages Of Evidence Based Practice Complacency and consensus The recognition of uncertainty Trials, laggards, innovation and diffusion Guidelines and “mindlines” The evidence based toolkit

Progress towards EBN (i)

Progress (ii) Policy EBN explicit in UK Nursing and Midwifery Council Standards and Code of Conduct “You have a responsibility to deliver care based on current evidence, best practice and, where applicable, validated research when it is available”.

Progress (iii) Nursing And National Standards Nursing and the National Institute For Health and Clinical Excellence (NICE) into professional knowledge Knowledge = “actionable understanding”

Progress (iv) education UK Nursing and Midwifery Council and Standards of Proficiency

Progress (vi) raw knowledge materials

Progress (vii) impact on clinical practice Then (1980s) Mainly venous in origin – compression bandaging is first line treatment >80% of leg ulcer patients managed in community by nurses (responsible for treatment decisions) Only <25% of those requiring compression bandaging received it Now (2000s) Screening for arterial disease using Doppler ankle brachial pressure index (ABPI) increased from 71.9% to 88.8% Assessment of patients’ pain increased from 65.8% to 83.4% Use of compression bandaging increased from 76.4% to 90.5% Time to healing reduced significantly

I’m confused…so what’s the problem? “As we know, There are known knowns. There are things we know we know. We also know There are known unknowns. That is to say We know there are some things We do not know. But there are also unknown unknowns, The ones we don't know We don't know.” © Rumsfeld, Feb. 12, 2002

A “Known Unknown” The relationship between information use and decision making

Two approaches – to judgement and decisions The black box of the “expert” decision maker Benner and “expertise” Qualitative “exploration” and description intangible Intra category comparison with no objective measures Expertise is what experts do… The empirical alternative Operationalise key terms Compare performance for tasks know something about Clinical judgement: assessment of alternatives Clinical decision: choosing an alternative Expertise: the ability to consistently make more good than bad judgements.

Knowns And Unknowns – Decision Making and Judgement What kinds of uncertainties, judgements and decisions do nurses face and how do they handle these? interviews observation and Q methodological modelling with 200+ nurses in primary and acute care. Thompson et al. Journal of Advanced Nursing 2001 – 2004

Types of uncertainty INTERVENTIONS Targeting Timing Prevention Referral ASSESSMENT DIAGNOSIS COMMUNICATION SERVICE ORGANISATION/DELIVERY INFORMATION SEEKING EXPERIENTIAL

How Often Do Nurses Face These Uncertainties? Once every 30 seconds in critical care (Bucknall, 2000) Circa 50 decisions every 8 hour shift in Medical Admissions (Thompson et al – 2005) 5 judgement or decision challenges per consult for health visitors.

How do nurses respond to uncertainty? Experiential/internal knowledge Very limited textual information use and for certain kinds of decisions (British National Formulary and local protocols) 90 hours of primary care = 1 telephone call 180 hours of acute care (1080 decisions) = local protocols x4 times, BNF x50 times). ‘sophistication’ and technology doesn’t matter (Randell et al. 2007). Demography and biography poor predictors of use

Explanations? barriers to research utilisation No time, no access, no skills, no control interventions to increase research use ineffective It’s nurses’ DECISIONS themselves that influence information use!

The theory – cognitive continuum Hamm,R (1988) in Dowie & Elstein, Clinical Judgement and decision making, Cambridge University Press

So… EBN all about combining information information handling and cognition depends on: The ways that nurses structure decisions The time available The ‘visibility’ of decision making required More time, more structure, and more visibility = greater use of research in decision making Problem – how to unpack information use in context of cognition and decision making and link to decision performance/expertise?

Expertise [properly] defined! In English: Decision making quality/achievement is a function of the nurse’s judgement consistency, the “fit” between decision task and the nurse’s way of thinking and the uncertainty in clinical practice. Brunwik’s lens model equation AAARGH….

How (i) methodology Social judgement lens modelling Achievement (Ra) Linear reasoning (G) Non linear reasoning (C) Control (Rs) Unpredictability (Re) Signal detection modelling d’ (or ability to discriminate signal from noise) Β (decision threshold) riskNo risk YesTPFP noFNTN

How (ii) method 245 acute care nurses Critical care experience & non-experienced UK, Canada, Australia, Netherlands 50 scenarios – perioperative MI 50% of arrests have documented but unacted upon changes in basic markers (BP, resps, pulse) Changes result in intervention only 2.8% of the time (Daffurn et al, 1994) Criterion: Modified Early Warning Score predicted outcome (true positive rate = 72%) Varying educational levels Variable time pressure and a protocol Thompson et al. journal of clinical nursing (in review)

We found Significant variability in estimated likelihood, Dx judgement of risk, and Rx (intervention) decisions despite identical information Dx = 3/50 through 50/50 Rx = 5/50 through 48/50 Achievement/accuracy.42 ( ) Consistency.79 ( ) Linear reasoning.50 ( ) >Rm = >achievement Rm.52 p<0.001) Mean R ( ) Non-linear reasoning.06 ( )

Time and experience (i) Mean95% CI d'Time pressure No time pressure lnβ Time pressure No time pressure

Time and experience (ii) No time pressure time pressure

Variability: evidence based protocol use UKNetherlandsCanadaAustralia % contribution to judgement

To what extent are nurse decisions evidence based NOW? Is research knowledge even part of nurses’ decision ingredients | information behaviour? To what extent do nurses’ decisions mirror research knowledge? Yes EBN in some nurses, for some decisions, in some contexts. (time, structure and visibility) Good information ≠ good decisions Expectation management No time for benefits of experience = no benefits

What’s the potential? What happens if we educate all nurses for uncertainty not certainty? Can large scale gains in quality (Linda Aiken’s) be replicated on a much smaller scale and with performance measures? Do we need to rethink Benner and nursing given differences in decisions? expertise in all contexts and all decisions within clinical domains? What happens if we fit decision technologies to decisions?

More Research Needed! Decisions and judgements as a dimension of research-utilisation and knowledge transfer studies? Challenges of evaluating decision technologies Context and decision specific Study design

Some good news: nursing started early… Florence Nightingale’s “coxcomb” Blue = contagious disease Red = deaths from wounds Black = other causes Jan 1855: 3168 deaths 32k manpower that month 1,174/10k overall mortality rate 1,023/10k contagious mortality rate  disease alone would have killed the British army in the Crimea