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

3. www.monash.edu.au 3 AUSTRALIA

4. www.monash.edu.au 4 Brisbane Sydney Hobart Adelaide Canberra Melbourne Victoria Darwin Perth

5. www.monash.edu.au 5 East Gippsland VICTORIA AUSTRALIA Bairnsdale Melbourne

6. www.monash.edu.au 6 Cann Rv EAST GIPPSLAND VICTORIA AUS Swifts CK Buchan Dargo Gelantipy Bairnsdale Moe

7. www.monash.edu.au 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 B911.45 hrs3.15 hrs4.45 hrs C1001.30 hrs3.0 hrs5.3 hrs D1141.40 hrs3.10 hrs5.4 hrs E1632.0 hrs3.5 hrs5.0 hrs Bush Nursing Context -1:

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

11. www.monash.edu.au 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. www.monash.edu.au 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. www.monash.edu.au 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 1988. HARBISON, J. (2001) Clinical decision making in nursing: theoretical perspectives & their relevance to practice. Journal of Advanced Nursing, 35, 126-133.

14. www.monash.edu.au 14 Types of knowledge.

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

23. www.monash.edu.au 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. www.monash.edu.au 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

25. www.monash.edu.au 25

26. www.monash.edu.au 26 Contact details: Mollie Burley Center for Multi-disciplinary Studies Monash University School of Rural Health PO Box 973 MOE Victoria Australia 3825. mollie.burley@med.monash.edu.au