Family Practice Advance Access originally published online on June 17, 2005
Family Practice 2005 22(5):490-497; doi:10.1093/fampra/cmi042
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Nurse practitioner and practice nurses' use of research information in clinical decision making: findings from an exploratory study
Department of Health Sciences, Area 2, Seebohm Rowntree Building, University of York, Heslington, York YO10 5DD, UK
Correspondence to Dorothy McCaughan; Email: dmm5{at}york.ac.uk
Received 11 October 2005; Accepted 4 April 2005.
McCaughan D, Thompson CA, Cullum NA, Sheldon TA and Raynor P. Nurse practitioner and practice nurses' use of research information in clinical decision making: qualitative findings from a national study. Family Practice 2005; 22: 490–497.
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Abstract |
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Background. There is a lack of evidence regarding the kinds of decisions made by primary care nurses and the information sources they use in clinical decision making.
Objective. To describe the decisions made by nurses working in general practice and the sources of information they use to underpin those decisions.
Methods. Qualitative methods (interviews, observation, documentary analysis) were used to collect data on the clinical decision making and information seeking behaviour of a purposive sample of 29 practice nurses and four nurse practitioners from general practices in the North of England. Data were collected November 2001–September 2002.
Results. A seven-fold typology captured the types of decisions the nurses made on a daily basis concerning assessment, diagnosis, intervention, referral, communication, service delivery and organization (SDO) and information seeking. Faced with clinical uncertainty, the majority of the nurses in the study relied on personal experience, or obtained advice and information from GP or other colleagues. These ‘human sources’ of information were overwhelmingly preferred to text or on-line resources. Despite encounters with evidence-based resources through continuing professional development, the nurses rarely used them to seek answers to routine clinical questions.
Conclusion. The decisions of the nurses in the study were mainly concerned with undifferentiated diagnosis and treatment, in the context of acute conditions and chronic disease management. ‘Human sources’ of information were preferred to any other; however, we do not know whether information obtained from colleagues is based on research.
Keywords. Decision making, information use, practice nurses.
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Introduction |
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New roles for nursing are having a major impact on service delivery in primary care.1–3 Little is known about how nurses are working in these roles. For example, very little existing research investigates the types of decisions nurses make in routine practice and the sources of information that inform these decisions.4,5
Primary care nurses, like other health care professionals, are expected to incorporate ‘best evidence’ into their clinical decisions, and therefore require skills in accessing, retrieving, appraising and applying research findings.6 Studies reveal that most doctors support the notion of evidence-based health care in principle, yet only a fraction acquire the necessary skills.7,8 Given that nurses are increasingly taking on responsibilities traditionally regarded as the province of doctors, it is pertinent to examine whether nurses are also struggling to implement evidence-based practice.
Kassirer9 questions whether nurses are adequately prepared for autonomous decision making, as this involves dealing with diagnostic uncertainty and complexity, which can provoke anxiety in nurses.10 Nurses' capacity for autonomous decision making may also curtailed by a perceived, or actual, lack of control over relevant factors, such as budgetary considerations.
This paper presents some of the results from a study designed to explore the nature of the decisions made by primary care nurses during their routine work, their perceptions of the access and usefulness of information for practice, as well as their perceptions of the need for research evidence to support clinical decision making.
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Methods |
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The research was conducted in GP practices in the North of England, in three case study sites with contrasting socio-economic, demographic, and nursing skill/role mix profiles (Box 1). Ethics approval was obtained from the three Local Research Ethics Committees. Piloting was in a site unconnected with the main study.
| BOX 1 Case site characteristics
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Design
Case study design using qualitative methods: interviews, observation and documentary analysis.
Participants
A letter explaining the study was sent to nurses working in all (143) general practices in the study sites with copies of a screening questionnaire. This was derived from a critical review of the literature of nurses' use of research information, and addressed variables previously associated with research utilization.11 We received completed questionnaires from 146 nurses in 80 practices. A purposive sample of informants was selected according to age, mode of training, professional and educational qualifications and any previous involvement in research. The total sample comprised 29 practice nurses and 4 nurse practitioners (nurses who held degree-level RCN Nurse Practitioner Award and/or a Masters degree in Advanced Clinical Practice) (Box 2). Practice nurses from all three sites were sampled but the nurse practitioners were from a single site, as none were identified in two of the three case sites. Work settings varied from single-handed practices to large medical group practices.
| BOX 2 Demographic data
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Data collection
Interviews. In-depth interviews (circa one hour) were conducted with 33 nurses concerning the use of research-based information in clinical decision making. Interviews were tape recorded, transcribed verbatim and verified for veracity of transcription, before being imported into the qualitative data analysis package Nudist NVivo (http://www.qsr.com.au) to facilitate data handling.
Observation. Nurses were observed (120 hours) during consultations to capture data on decision making and information use in ‘real time’. The researchers (DM and PR) adopted the participant-as-observer framework.12 Interview and observation of the same individuals allowed us to compare the nurses' accounts of their information seeking behaviour with the observed ‘reality’. Observational material was recorded in the form of field notes, typed up in full by the researchers and imported into the Nudist NVivo package.
Documentary/resource audit. An audit was conducted of all the practice-based information resources available to each of the nurses to allow for cross-referencing of sources referred to during interviews, and to gain insight into the kind of information typically available to practice nurses. We experienced problems with access in a minority of practices; elsewhere, extensive audit was undertaken: all written materials in the nurses' office, practice library or ‘resource room’ were inspected and a record made of publication date, references to a research base, the origin and nature of the resource and its clinical focus. Availability of computerized sources of information was also noted.
Analysis of data
Analysis of interviews was concurrent with data collection so that new themes could be identified for inclusion in subsequent interviews. Data collection continued until saturation occurred, whereby no new or relevant material emerged. Data were analysed using an iterative framework of constant comparison, reflexivity in data collection and frequent re-analysis of data as new themes emerged.13 This model of analysis fosters transparency and rigour in the analytical process.14
The project team scrutinized transcripts of the interview and observational data to understand the types of decisions nurses made. Classification of decisions was carried out by members of the research team with different levels of involvement in the project. We used a multi-rater Kappa statistic to measure inter-rater reliability, and promote focus in the team discussion of decision types.15 Kappa scores between team members, measured over four time periods, demonstrated increased levels of agreement throughout the process. On the last occasion, all team members' scores were above 0.71, indicating a ‘substantial’ level of agreement.16
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Results |
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Interview, observational and audit data yielded information about the types of decisions practice based nurses make and the sources of information that underpin those decisions.
What types of decisions do practice nurses and nurse practitioners make?
The nurses responded well to a question asking them to ‘run through’ decisions taken in relation to practice during a previous span of duty. Almost all of their decisions were captured by a seven-fold taxonomy of decision types (Box 3); the largest number related to questions concerning interventions. Subcategories of intervention related to decisions about timing and targeting, and interventions classified as ‘preventive’. Many decisions were concerned with how best to communicate to patients the risks and benefits associated with various interventions.
| BOX 3 Decision typology
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Sources of information used in clinical decision making
Personal experience. Interview and observational data highlighted the importance of the nurses' personal experience as a knowledge source for practice, particularly with regard to wound care, to the extent of their being dismissive of research evidence:
"... and if somebody came out with a piece of research and said ‘that didn't work’ you probably wouldn't believe them because you had such success stories with it. So you tend to stick to age-old favourites, to what you know has worked with your patients in the past". PN6, Case site 3
Human sources. Observation revealed that when nurses experienced clinical uncertainty, they preferred to seek information from a colleague, rather than electronic or textual information. Most often, this was the GP, but other colleagues were also viewed as reliable and trustworthy sources of information. As one nurse stated succinctly at interview "you just know who has got the knowledge you need", PN1, Case site 1.
GPs were generally viewed as particularly accessible, partly because they were usually immediately to hand and could resolve a query straight away, and also because they were perceived as supportive and helpful: "our GPs are very, very accessible they're not ‘don't bother me nurse’ types at all and you can ask them anything, anytime", PN5, Case site 3.
Information from commercial representatives and sponsored ‘nurse advisors’ was valued and seen as readily available—possibly reflecting their highly proactive and personalized approaches to targeting the nurses with information:
"The drug companies have asthma specialist nurses. All they do is go around their own area, checking up the practice nurses have got all the bumph and help they need, and even offering to help with your audits and set things up if needed and it's quite helpful to have somebody to turn to or you can ring up if you have got a problem and you can discuss it with them". PN2, Case site 2Some, but by no means all, of the nurses sounded a note of caution in relation to commercially sponsored information: "we get a lot from reps, you know, I do read that, but with rather a cautious hat on". PN1, Case site 3
‘Humanised’ sources of information. When information was sought using technology, nurses appeared to favour sources incorporating some form of human contact. Help-lines were used for queries relating to travel health and wound care, with nurses showing a preference for a voice at the end of the telephone, rather than an answer machine:
"There's usually an answer machine and goes through a whole load of questions, and you think 'Oh God, well I can't cope with this". PN7, Case site 2Participation in professional email discussion groups was popular as a means of networking with colleagues (several practice nurses expressed feeling rather isolated in their job) and keeping up to date with practice developments.
While the explicit use of clinical guidelines was rarely observed (Box 4) nurses saw them as useful for decision making if they had been ‘endorsed’ by clinicians perceived as clinically credible and accessible:
"We are lucky to have a superb gynaecologist and sexual health doctor who is nationally recognised for her work and she is very, very approachable ... she will actually take personal calls from you, she will actually respond to your call, so we use a lot of her guidelines, a lot of the GUM guidelines, regional guidelines ...". NP3, Case site 1
| BOX 4 Use of clinical guidelines and protocols
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Information technology and text based resources. Audit of available sources of information was undertaken in each practice. The practice nurses, in contrast to their district nurse and health visitor colleagues, all had ready access to computers. However, they were largely unaware of the wide range of on-line resources provided through the practice (for example, the on-line version of the BMJ publication ‘Clinical Evidence’), or they gave reasons for not using them. Amongst the nurses, computer use was mainly confined to accessing patient records, and for administrative and audit purposes.
Observation revealed nurses' ‘real time’ use of electronic media (Internet, databases and other on-line resources) and text (paper based) resources. During 224 patient consultations, sources of information were used 57 times (25% of consultations); on 55 occasions, text rather than electronic sources were accessed. Electronic media (British National Formulary on-line) were accessed only twice, both times by the same practitioner, in response to drug related queries. Information-seeking occurred almost exclusively in relation to the ‘structured’ clinical uncertainty surrounding medications, that is to say, to check dosage, frequency of administration or side effects of drugs. Sources accessed for these purposes included the British National Formulary and the Monthly Index of Medical Specialties (MIMS) (text and electronic), drug product information sheets, an HMSO publication on immunization and vaccination, information charts from journals and travel health websites.
The single most frequently used source of information amongst the practice nurses was the text based BNF, revealing the importance of drug related issues of uncertainty for this group of nurses. Interestingly, drug-related enquiry was the only context in which information seeking occurred in the presence of the patient. This may have been because the nurses anticipated finding answers to their questions about medications quickly and easily, due to familiarity with the format of the BNF from the earliest stages of their training, and its well-established use in practice.
Database use. Levels of awareness of CD Rom and electronic databases (eg Medline and Cinahl) amongst the nurses were generally low, and those who had a higher awareness did not appear to use them in practice. Some nurses described their frustration on trying to use the Cochrane Library:
"The problem is with some of them you don't get the full document, you just get an abstract, don't you, which is frustrating". PN3, Case site 2A lack of time and confidence were cited as the main reasons for not using databases during consultations:
"I don't get time and I would never use it [the Cochrane Library] with a patient sat here, I don't feel confident enough to use it with a patient sat here". PN6, Case site 1
Internet use. At interview, the majority of nurses reported very limited use of the Internet at work (other than for the email communication mentioned above) for a variety of reasons (Box 5). Those nurses with adequate IT skills reported using it to obtain patient information leaflets from sites such as Diabetes UK and the British Heart Foundation. Unfortunately, less credible sites were also seen as easily accessible for this purpose: one practice nurse described retrieving information from www.diabetes.com, which she believed was based on ‘national guidelines’ and independent. In reality, this is an American site sponsored by a large pharmaceutical company. Certain Internet sites were considered more user friendly than others, for example the BMJ website was mentioned several times.
| BOX 5 Reasons given by nurses for not using the Internet
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Internet use at home was reported more commonly than at work, for several reasons: easier access, less time pressure and the presence of family members (expert users) who can be relied on for help, or even to carry out the task. Internet use at home was mainly confined to accessing information for CPD, rather than for a specific work related enquiry.
Library use. Library use was reportedly limited due to difficulties with access (hospital/university libraries) and lack of protected time (practice library); it was mainly associated with academic study rather than clinical enquiry.
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Discussion |
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Drawing on the interview and observation data concerning the decisions of practice nurses, a seven-fold decision typology of the kinds of decisions routinely made by the practice nurses, was developed; whilst not exhaustive, it represents an initial attempt to classify decisions, so that we might begin to assess how amenable these are to evidence from research.
The majority of decisions were concerned with differential diagnosis, choice and delivery of interventions, within the context of the management of acute illnesses, minor injuries and chronic disease. There was no difference in the pattern of decision making between practice nurses and nurse practitioners. This may be explained by the fact that the majority of the practice nurses were seeing patients with symptoms similar to those of patients consulting nurse practitioners.
Personal experience, together with information and advice from colleagues, was considered more accessible and useful for clinical decision making than text or computer based sources of information. Written sources of information were accessed during consultation only in relation to drug related enquiries, which frequently acted as a trigger for information seeking behaviour by the practice-based nurses. In contrast, referral to colleagues for information (concerning diagnosis and treatment) during consultations was common. Whilst we do not know whether participants altered their behaviour during observation, triangulation of interviews and observation suggests that the nurses behaved as they said they would.
Participants reported that they were much more likely to use the Internet at home than at work, and primarily for CPD related study. During 224 patient consultations, the Internet was used on just two occasions for information retrieval connected to clinical queries.
Observation revealed no differences in the information seeking behaviour of nurse practitioners and practice nurses. However, nurse practitioners were drawn from only one of the case study sites and the sample size was small and it is possible that differences may have been detected with a larger sample.
Like all case studies, this study has some limitations: our aim was to explore and illuminate the issues associated with the complexity of clinical decision making, to capture ‘rich description’, rather than to produce probabilistically generalizable findings. Notwithstanding, explanations arising from case study analysis, based on the provision of ‘thick description’, may be considered logically transferable to similar settings.17
Comparison with other studies
The study findings are consistent with other research on doctors' use of information in clinical decision making which reveals that other professionals dominate as the prime source of information in uncertain clinical situations. In their study of US physicians, Covell et al.18 showed that while individuals may claim to access research knowledge via media such as journals, in reality, as revealed through observation, they consult colleagues from their own and other professions. Interviews with 24 UK GPs8 about the sources of information they used in situations of clinical uncertainty, revealed GP partners and hospital doctors to be the main sources.
Our results accord closely with those of Cogdill's19 study of North American nurse practitioners which revealed that the information sources used most frequently ("a few times per week or more") were physician colleagues (in relation to diagnostic uncertainty) and drug reference manuals for needs relating to drug therapy; in his study, there were no instances of use of computer-based sources of information. Others outside the UK20,21 have shown that nurses' use of on-line resources at work is low compared with other professional groups, despite adequate access.
Implications of the study
As far as we know, this study is the first of its kind in the UK. It provides insight into practice-based nurses' clinical decision making through extensive observation of their actual information seeking behaviour during clinical encounters with patients.
As with physicians,22 consultations with colleagues were found to be the most frequently used source of information, particularly in relation to diagnostic and treatment uncertainty. Although, again, as with doctors, it is feasible that at least some of the information nurses receive from colleagues is derived from research. Specifically, the colleagues that act as influential information sources, may themselves be active text or on-line research-based information seekers. However, this was not the impression gained from our study sample.
Educational programmes need to highlight the use of appropriate information resources and the limitations of over-reliance on experience as the sole source. Information from consultations may be supplemented with evidence derived from clinical research to support diagnostic and treatment decisions. Our study has indicated the relevance of evidence from appropriate research designs for the types of decisions that practice nurses make routinely.
Practice nurses and nurse practitioners have easier access to computers than other groups of nurses working in the community23 but require further training in IT and critical appraisal skills, along with protected time, if they are to exploit the information resources that are becoming increasingly available to them on-line. CPD provides a route to acquiring these skills, but opportunities for practice nurses, many of whom work part time, to access training and education are dependent on a number of factors beyond their control, and a national strategy is required to develop this group of nurses to their full potential.
Professional development in information retrieval and its clinical application should ideally be offered to all members of the primary care team in an integrated approach, based on the development and adoption of a coherent practice development plan.
Conclusion
Nurse practitioners and practice nurses prefer to rely on their own experience or that of their colleagues to answer clinical questions. It is easy to assume that such information is uninformed by research—this may not be the case. More research is required into uncovering the ‘audit trails’ associated with colleague advice, or its reliability and validity. Nurses do not routinely seek answers from research when faced with clinical uncertainty, even though the decisions they make could be optimised using evidence from valid, relevant research (particularly RCTs and sytematic reviews for intervention-oriented decisions). On-line and text based sources of information are not used during their consultations with patients, except in the context of drug related enquiry. For the time being at least, it would appear that practice based nurses are not engaging with the latest advances in information technology offered by the NHS IT strategy.24
Declaration
Funding: the study was funded with a grant from the Medical Research Council (Grant number G 9900274 and Grant ID 47993).
Ethical approval: obtained from the appropriate Local Research Ethics committees for the research to proceed.
Conflicts of interest: none
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Acknowledgments |
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The research team would like to thank all the clinicians and managers who facilitated research access and allowed us to interview and observe them in practice. We would particularly like to express our gratitude to patients who permitted us to carry out observation during their consultations with nurses. The views expressed in this paper represent those of the research team, and do not necessarily reflect those of the funding body.
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