Why providing information for evidence based decision making by nurses is a bad idea…

1. Why providing information for evidence based decision making by nurses is a bad idea… Carl Thompson UK Department of Health, Senior Research Fellow

2. What is he talking about…? • That the context for EBN means that information (no matter how good the quality) is never enough • 10 information myths that illustrate the reality of EB decision making • Nurses vary enormously in their handling of even experientially-generated, relevant, knowledge – so what hope for research info. • That using evidence involves costs, benefits, trade-offs: it’s a PURCHASING decision made by members of a COMMUNITY (of practice)

3. context (errors, information, combination and unknowns) Patient Safety and decision making

4. context (research ) • 2 multi site case studies (1997 – 2002) • theoretically sampled • 200 in depth interviews • 400 hours observation (decision making and information use in action) • 4000 documents audited • Q methodological modelling (242 nurses) • Social judgement modelling (critical care and community nurses, 2003 – pres) • “Think aloud” and video Thompson et al. 1999, 2000, 2001 2002, 2004, in press

5. context (information to knowledge) 10001000110011010… if X then Y and Z

6. Context (learning) Behavioural trends, Changes and Incremental modification Repetition Activity Behaviour Practice Training Observation experience Learning Observable…unobservable…observable Hilguard, Marquis 1961

7. Typology* of decision related uncertainty • Intervention/effectiveness • Targeting • Timing • Prevention • Referral • Communication (risks and benefits) • SDO • Assessment • Dx • Information seeking • Experiential, understanding or hermeneutic * Kappa 0.82 Thompson et al. IJNS 2004 Thompson et al. 2000, 2001 2002, 2004; McCaughan et al. 2002

8. The information response • 270 hours of PCO 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 PCO members otherwise BNF (x2 on-line) • 180 hours of acute care observation (circa 1080 decisions) only 2 forms of text based information used (local guidelines x 4 and BNF x 50)

9. The 10 information for nurse decision making ‘myths’ • Only objective information is valuable • More information is always better • Information can be transmitted without context • Information can only be acquired from formal sources • Relevant information exists for every need • Every information need has a solution • Information can always be made accessible • Functional units of information fit the functional units of individuals • Time and space don’t matter • External information and internal reality can be united without conflict

10. only objective information is valuable • Normatively – possibly • Descriptively - untrue

11. more information is better • Problem is making sense of existing information rather than adding to it.

12. 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

13. 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

14. relevant information exists for every need • Nurses don’t recognise (or cannot verbalise) information needs • Satisficing • [over] confidence quickly acquired (Urquhart 1999).

15. every information need situation has a solution • Information seeking = transforming need into workable format • unfitness for purpose = negative feedback

16. information can always be made accessible • Physical sense = yes • Intellectual/cognitive = no

17. 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

18. 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) Mode of decision making intuition Analysis

19. conflict free connections between external information and internal reality • Defensiveness and conflict • We simply do not know!

20. What is SJT? ‘ecology’

23. Intra-group variation

24. Information utility

25. High school College graduate

27. Purchasing behaviour Post purchase feelings Felt need Pre-purchase activity Purchase decision Use behaviour Post use evaluation Info need recognition Info search behaviour Evaluation of Info alternatives Use behaviour Information behaviour Kotler 1967; Case 2002

28. knowledge knowledge • Lives in the human act of knowing • Is tacit as well as explicit • Social as well as individual • Is dynamic