The face of evidence in nurses

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The face of evidence in nurses clinical decision
making.

• Carl Thompson, Centre for Evidence Based Nursing,
  Department of Health Studies, University of York.

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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?

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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 gt100 people.

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Q methodology

• construction of a Q sample
• Q sorting
• Interpretation I) statistical
• Interpretation II) qualitative interpretation
• Conventional r methodological regression
  modelling.

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decisionsdecisions
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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

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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

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

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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

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Timing decisions

• Choosing a time to commence asthma education
•  
• When to commence asthma education on newly
  diagnosed asthmatics?

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Communicating risks and benefits

• A patient coming for a 1st 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?

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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?

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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?

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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?

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• 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 somebodys degree etc.

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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.

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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 cant?)
• Solutions? Product improvement and core skills
  related?

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Lacks confidence(ii)

• agree
• Statistics put me off research (5)
• too academic (5)
• too complicated (5)
• dont 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)
• hasnt 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

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Lacks confidence(ii)

• agree
• Statistics put me off research (5)
• too academic (5)
• too complicated (5)
• dont 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)
• hasnt 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

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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

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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
• Dont have the facilities
• RD 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

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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
• Dont have the facilities
• RD 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

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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

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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.

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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)

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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!
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Whats 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.

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Whats 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 gt10years
• media articles
• the internet (www)
• text book lt10years
• product helplines
• journal club
• JAN research study
• BMJ research study

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Questions

• Should we be questioning nursings evidence base?
• What does a qualitative clinical question look
  like?

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Knowledgefit for purpose?
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• 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?

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• 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?

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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