Clinical Decision Making, Information Use and Practice Development...

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Clinical Decision Making, Information Use and
Practice Development...

• Dr Carl Thompson, Dr Nicky Cullum, Dorothy
  McCaughan, Prof..Trevor Sheldon, Prof.. David
  Thompson, Dr Anne Mulhall.

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For the snoozers...

• Nursing decisions ARE amenable to research
  evidence
  
• clinical questions rarely involve blue vs black
  pens!
  
• Text based resources bad human clinically
  credible experts good.
  
• Bureaucratic PDN validation bad PDN as expert,
  reflexive source of implementation advice good.
  
• Diagnosis...targetingmarketing meaningful
  follow up all good

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WHY? The research questions

• The potential for EBN
• what kinds of decisions do nurses make?
• what stops them using research in practice?
• how do they access information for practice?
• how useful do they find research information?

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How? The methods...

• NHS RD Methods to improve the implementation of
  research findings
  
• 3 large case sites ( 2 pilots) Medicine,
  Surgery, CCU
  
• qualitative
• 108 interviews
• 180 hours of observation
• 4000 ward based documents audited
• quantitative
• 122 x3 Q sorts - used to model shared sets of
  values around key questions
  
• regression modeling of associated demographics
• Analysis between method and case triangulation,
  cross comparison.

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Whatsome of the results

• Nurses make decisions!
• selecting interventions
• targeting
• timing
• communicating risks and benefits
• hermeneutic/experiential
• service organisation, delivery and management

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They can convert these decisions into Evidence
Based PICO questions

• E.g.
• In elderly and inactive patients, who may require
  surgical intervention, which is the most suitable
  pressure relieving mattress to prevent pressure
  sores?
• Is there a risk assessment tool available that
  will accurately predict which group of patients
  will benefit most from anti-embolic stockings?
  
• When to commence asthma education on newly
  diagnosed asthmatics to make sure that self
  management is most effective ?
  
• Would I be better talking and explaining rehab
  with the patients family present so that a clear
  understanding is obtained prior to the patients
  discharge?
• How should I organise handover so that the most
  effective form of communicating information
  results?

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What stops nurses using research?

• dont understand?
• low confidence
• colleagues
• low skills and low motivation.

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Improve access then?

• Dont use text based resources
• 180 hours 4 protocols, BNF and errr thats it!
• 4000 documents average age 5 years, 42 had
  audit trail only 10 any kind of evidence base.
  
• Human sources dominate

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But we are useful...

• Yes and no!
• your products are seen as useful as part of the
  machinery of a Trust less so.
  
• Need
• guiding or prescriptive messages
• combined with experience
• structurally supported development processes
• technology based

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Implications thengeneral

• Work with what you have gotdiagnoses (NHS CRD,
  1999)
  
• target
• market
• multifaceted interventions
• meaningful follow up

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Implications PDNs

• Bridging roles EBN as well as practical skills
• generic roles fire fighting
• reactive as well as proactive
• market your efforts - publish, expose to scrutiny
  (not just other PDNs!)
  
• clinical credibility and applicability currency
  for change NOT research process
  
• Harness the power of change agents

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The vision?
they Practice Development Nurses facilitate i
nnovation and the development of research-based
clinical practice within clinical areas. They
have a a broad clinical nursing foundation,
together with a high level of skill and knowledge
relevant to leadership, management of change and
use of research in nursing practice.
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How not to achieve it...

• Bottom line clinical relevance is the key to
  successful research and organizational change
  
• Nurses make decisions
• These decisions are often associated with
  uncertainty
  
• Nurses can (if given the opportunity) convert
  uncertainty into focused (answerable) clinical
  questions.
  
• Provide help in getting the answers to those
  questions valid role for PDNs??