1. The face of evidence in nurses’ clinical decision making. Carl Thompson, Centre for Evidence Based Nursing, Department of Health Studies, University of York.

2. Research Questions… Do nurses see research information as useful? How do nurses access research based information? What stops them using research based info? WHAT IS THE POTENTIAL FOR EBN?

6. Methodology…  Mixed qualitative and quantitative case site design  Purposive sampling of cases (sites), wards, individuals and practice  130 interviews  180 hours of observation  Q methodological data on >100 people.

7. Q methodology…  construction of a Q sample  Q sorting  Interpretation I): statistical  Interpretation II): qualitative interpretation  Conventional ‘r’ methodological regression modelling.

8. decisions…

9. To err is human…  Bounded rationality and satisficing means failure  Incomplete knowledge means failure  Knowledge base itself means failure (heuristics)  Selectivity  Availability  Confirmation bias  Hindsight bias  Overconfidence

11. EBN can help!  Converting clinical uncertainty to clinical questions  Helps frame problems  The search process systematises the knowledge gathering process  Generates answers or at the least informed non- decisions  Appraisal and meta analysis help combat selective overviewing  Most of all it helps avoid the common scenario of information overload…

13. But can nurses ask clinical questions based on the decisions they face…?

14. Tentatively yes…  Asked nurses to reflect on a clinical decision they had made and to convert this into a clinical question (few examples & no training)  Good results – all did it (although six chose examples!)  Significant minority (around 30%) conformed to the 3 or 4 part evidence based focussed clinical question format.

15. Intervention or effectiveness  Which kind of mattress to nurse a frail elderly man on who has been admitted with bowel obstruction  In patients who are elderly and inactive, and may require surgical intervention, which is the most suitable pressure relieving mattress to prevent complications i.e. pressure sores

16. Timing decisions  Choosing a time to commence asthma education  When to commence asthma education on newly diagnosed asthmatics?

17. Communicating risks and benefits  A patient coming for a 1 st dose of chemotherapy asks the risks and side effects of that treatment  How many patients receiving chemotherapy will experience side effects and will the benefit of treatment outweigh the risks?

18. targeting  An elderly lady who is bed bound. Her sacrum is starting to become red, she is able to move herself around the bed but is concerned about pressure sores.  At what point would a special pressure sore mattress or bed be brought into the management of this patient?

19. Organisation and service delivery?  Choosing new pressure relieving mattress for unit.  In a coronary care unit with no age limit admission criteria, which pressure relieving mattress system will prove to be most effective, durable and financially viable?

20. So far so good?  Reasonable to hypothesise that given a solid (and quickly acquired and reinforced) skill nurses could improve the ways in which they engage with research evidence?  Maybe, maybe not?

21. I do not seem to use research much to make my decisions. I feel that this is justified because I am looking at the patient holistically. This is why the patient and family come before research. The first and most useful sources I felt were experienced nurses, and particularly specialist nurses for this area if there were any. This is because these nurses should be up to date with methods and will have tried them, rather than going on research which is sponsored by drug companies, or for somebody’s degree etc.

22. barriers to research evidence use…  Q sample of 60 items (based on first level interpretative coding schema)  Open sample (not structured to ‘test’ or operationalise a particular theory)  Just four factors account for 37% of the variance associated with the individuals.

23. Lacks confidence could try harder…  Accounts for most of the variance (12%)  Problem is with the stuff we (researchers) produce  Causes conflicting feelings (want to be doing the right thing but can’t?)  Solutions? Product improvement and core skills related?

24. Lacks confidence(ii)  agree  Statistics put me off research (+5)  …too academic (+5)  …too complicated (+5)  …don’t have necessary computer skills (+4)  …no real confidence in reading research  Poor basic education  No facilities…  Other nurses are a block on using research  disagree  …best left to college leavers (-5)  …hasn’t resulted in better decisions  Culture not geared up for using research  More for manager than practicing nurses  Its unrealistic using research information in clinical decisions as… not suited

26. Lacks confidence(ii)  agree  Statistics put me off research (+5)  …too academic (+5)  …too complicated (+5)  …don’t have necessary computer skills (+4)  …no real confidence in reading research  Poor basic education  No facilities…  Other nurses are a block on using research  disagree  …best left to college leavers (-5)  …hasn’t resulted in better decisions  Culture not geared up for using research  More for manager than practicing nurses  Its unrealistic using research information in clinical decisions as… not suited

27. Confident underachievers?  Accounts for similar amount of variance (10%) as previous factor  Not afraid of research  Broadly positive to research info generally  Organisational cultural barriers are biggest obstacle

28. Confident underachievers (ii)  Agree  Other nurses block using research  Facilities to help use research not based on site  Used in the past cost too much time and money  Don’t have the facilities  R&D support structures hinder rather than help  Medics block research use  Geographical specificity and TIME!  disagree  Too academic  Not practice related  Too wishy washy  Uses complex language  Too complicated  No motivation for using research

30. Confident underachievers (ii)  Agree  Other nurses block using research  Facilities to help use research not based on site  Used in the past cost too much time and money  Don’t have the facilities  R&D support structures hinder rather than help  Medics block research use  Geographical specificity and TIME!  disagree  Too academic  Not practice related  Too wishy washy  Uses complex language  Too complicated  No motivation for using research

31. So how ‘exactly’ does it work?  Third factor very similar to previous factor:  Confident  Good basic educational preparation  Differentiated by the degree of importance attached to  time  they have adequate computer skills  clinical credibility (read information if written by a nurse and most authors not credible)  Want more direction from research evidence.  Existing policies were seen as unwieldy

33. The Challengers?  Far too busy  confident in reading research  But no motivation to use it  Partly product related (stats and out of date)  Desire to have research built into existing technologies.

34. What about accessibility…  Q sample from sources quoted in interviews, observed and audited.  wound care case scenario.  3 factors = over half (54%) of the variance in the sample.  most accessible sources overwhelmingly human  Inaccessibility associated with more ‘transparent’ resources and helpful technologies (online databases, internet, journals)

35. Accessibility…  Most accessible  Clinical nurse specialists  Experienced colleagues  Link nurses  Registrars & Consultants (disputed!)  Least accessible  Local medical/ nursing librarian  Nursing directorates  Home-based internet  RCN direct  Medline/CINAHL Text-based technologies somewhere in the middle – but have to be developed by ‘locals’!

36. What’s useful…  Four factors account for 56% of the variance associated with the sorts.  First two together account for 45%  all the people who defined factor 2 did so negatively  in effect then a single factor that accounts for 45% of the variance.

37. What’s useful…(ii)  Most useful  clinical nurse specialists  link nurse  previous experience  ward manager/sister  the patient or family  local clinical guidelines/protocols  Least useful  textbook >10years  media articles  the internet (www)  text book <10years  product helplines  journal club  JAN research study  BMJ research study

38. Questions…  Should we be questioning nursing’s evidence base?  What does a ‘qualitative’ clinical question look like?

39. Knowledge…fit for purpose?

40.  How best to close some of the contradictions highlighted:  CNSs and link nurses seen as useful and accessible but no organisational or structural power  Huge efforts on the part of Trusts with little discernible impact should we divert resources?

41.  Would basic skills training make a difference?  Question development based on knowledge of decisions.  Effective and efficient use of existing resources  Training for uncertainty rather than certainty?

42. Future? Is the picture similar in primary care? Intervention studies to combat the skills and product-related problems National educational strategy Local and national developmental agenda