Dawn Dowding

AN AGENDA FOR CLINICAL DECISION MAKING AND JUDGEMENT IN NURSING RESEARCH AND EDUCATION

Nurses judgements and decisions have the potential to help healthcare systems allocate resources efficiently, promote health gain and patient benefit and prevent harm. Evidence from healthcare systems throughout the world suggests that judgements and decisions made by clinicians could be improved: around half of all adverse events have some kind of error at their core. For nursing to contribute to raising quality though improved judgements and decisions within health systems we need to know more about the decisions and judgements themselves, the interventions likely to improve judgement and decision processes and outcomes, and where best to target finite intellectual and educational resources. There is a rich heritage of research into decision making and judgement, both from within the discipline of nursing and from other perspectives, but which focus on nurses. Much of this evidence plays only a minor role in the development of educational and technological efforts at decision improvement. This paper presents nine unanswered questions that researchers and educators might like to consider as a potential agenda for the future of research into this important area of nursing practice, training and development.

Responding to uncertainty in nursing practice

Uncertainty is a fact of life for practising clinicians and cannot be avoided. This paper outlines the model of uncertainty presented by Katz (1988, Cambridge University Press, Cambridge, UK. pp. 544-565) and examines the descriptive and normative power of three broad theoretical and strategic approaches to dealing with uncertainty: rationality, bounded rationality and intuition. It concludes that nursing research and development (R&D) must acknowledge uncertainty more fully in its R&D agenda and that good-quality evaluation studies which directly compare intuitive with rational-analytical approaches for given clinical problems should be a dominant feature of future R&D.

The impact of an electronic health record on nurse sensitive patient outcomes: an interrupted time series analysis

OBJECTIVESnTo evaluate the impact of electronic health record (EHR) implementation on nursing care processes and outcomes.nnnDESIGNnInterrupted time series analysis, 2003-2009.nnnSETTINGnA large US not-for-profit integrated health care organization.nnnPARTICIPANTSn29 hospitals in Northern and Southern California.nnnINTERVENTIONnAn integrated EHR including computerized physician order entry, nursing documentation, risk assessment tools, and documentation tools.nnnMAIN OUTCOME MEASURESnPercentage of patients with completed risk assessments for hospital acquired pressure ulcers (HAPUs) and falls (process measures) and rates of HAPU and falls (outcome measures).nnnRESULTSnEHR implementation was significantly associated with an increase in documentation rates for HAPU risk (coefficient 2.21, 95% CI 0.67 to 3.75); the increase for fall risk was not statistically significant (0.36; -3.58 to 4.30). EHR implementation was associated with a 13% decrease in HAPU rates (coefficient -0.76, 95% CI -1.37 to -0.16) but no decrease in fall rates (-0.091; -0.29 to 0.11). Irrespective of EHR implementation, HAPU rates decreased significantly over time (-0.16; -0.20 to -0.13), while fall rates did not (0.0052; -0.01 to 0.02). Hospital region was a significant predictor of variation for both HAPU (0.72; 0.30 to 1.14) and fall rates (0.57; 0.41 to 0.72).nnnCONCLUSIONSnThe introduction of an integrated EHR was associated with a reduction in the number of HAPUs but not in patient fall rates. Other factors, such as changes over time and hospital region, were also associated with variation in outcomes. The findings suggest that EHR impact on nursing care processes and outcomes is dependent on a number of factors that should be further explored.

Diagnosis and management of people with venous thromboembolism and advanced cancer: how do doctors decide? a qualitative study

BackgroundThe treatment of cancer associated thrombosis (CAT) is well established, with level 1A evidence to support the recommendation of a low molecular weight heparin (LMWH) by daily injection for 3–6 months. However, registry data suggest compliance to clinical guidelines is poor. Clinicians face particular challenges in treating CAT in advanced cancer patients due to shorter life expectancy, increased bleeding risk and concerns that self injection may be too burdensome. For these reasons decision making around the diagnosis and management of CAT in people with advanced cancer, can be complex, and should focus on its likely net benefit for the patient. We explored factors that influence doctors’ decision making in this situation and sought to gain an understanding of the barriers and facilitators to the application of best practice.MethodsThink aloud exercises using standardised case scenarios, and individual in depth interviews were conducted. All were transcribed. The think aloud exercises were analysed using Protocol Analysis and the interviews using Framework Analysis.Participants: 46 participants took part in the think aloud exercises and 45 participants were interviewed in depth. Each group included oncologists, palliative physicians and general practitioners and included both senior doctors and those in training.Setting: Two Strategic Health Authority regions, one in the north of England and one in Wales.ResultsThe following key issues arose from the data synthesis: the importance of patient prognosis; the concept of “appropriateness”; “benefits and burdens” of diagnosis and treatment; LMWH or warfarin for treatment and sources of information which changed practice. Although interlinked, they do describe distinct aspects of the factors that influence doctors in their decisions in this area.ConclusionsThe above factors are issues doctors take into account when deciding whether to send a patient to hospital for investigation or to anticoagulate a patient with confirmed or suspected VTE. Many factors interweave and are themselves influenced by and dependent on each other. It is only after all are taken into account that the doctor arrives at the point of referring the patient for investigation. Some factors including logistic and organisational issues appeared to influence whether a patient would be investigated or treated with LMWH for a confirmed VTE. It is important that services are optimised to ensure that these do not hinder the appropriate investigation and management of individual patients.

Barriers to the diagnosis and treatment of venous thromboembolism in advanced cancer patients: A qualitative study

Background: Venous thromboembolism is common in patients with cancer and the risk increases with advanced disease. Evidence-based treatment is administration of low-molecular-weight heparin daily by subcutaneous injection. Clinical uncertainty exists as to whether treating venous thromboembolism in advanced disease is in the patient’s best interests. Aim: To explore the barriers faced by doctors when diagnosing and treating patients with cancer-associated thrombosis. Design: Qualitative, in-depth interview study using framework analysis. Participants: Forty-five UK doctors across urban and rural settings, from three specialties, oncology, palliative medicine and general practice, with a mixture of senior and junior staff. Results: Organisational constraints served to act as barriers to the diagnosis and treatment of this patient group. Issues were identified around access to diagnostic testing. A cancer-associated thrombosis patient having to wait for a scan as an inpatient was sometimes deemed unnecessary. Patient ambulance transport (especially transportation of hospice patients) was often viewed as inflexible and bureaucratic. Low-molecular-weight heparin prescribing had sometimes led to tension between the acute, community and hospice sectors about whose prescribing responsibility this was, with different areas having divergent ‘rules’ and practices. Finally, the doctors interviewed discussed the role of nurses. Conclusions: Multiple logistical barriers are hindering best patient care for people with cancer-associated thrombosis. There is scope for some of these barriers to be reduced to improve service delivery and ultimately patient care. The research team proposes practical recommendations, which could yield direct benefit for patients and the health services.

Conceptualising decision making in nursing education

The ability to exhibit sound judgement and decision-making skills is a fundamental requirement of undergraduate nursing curricula. In order to acquire such skills, students need to develop critical thinking ability, as well as an understanding of how judgements and decisions are reached in complex healthcare environments. The use of techniques such as problem-based learning, simulation and feedback has been hypothesised to help with the development of critical thinking skills. In addition, a curriculum that incorporates teaching on different ways in which judgements and decisions are reached can potentially help students identify how to avoid errors and mistakes in their clinical practice. Feedback has been shown to be a powerful tool to help with developing decision-making skills; evidence for other approaches to teaching critical thinking and decision-making skills is currently limited. This paper reviews theoretical concepts that provide a framework for decision making in nursing, as well as methods by which it can be taught.

The ethical decisions UK doctors make regarding advanced cancer patients at the end of life - the perceived (in) appropriateness of anticoagulation for venous thromboembolism: A qualitative study

BackgroundCancer patients are at risk of developing blood clots in their veins - venous thromboembolism (VTE) - which often takes the form of a pulmonary embolism or deep vein thrombosis. The risk increases with advanced disease. Evidence based treatment is low molecular weight heparin (LMWH) by daily subcutaneous injection. The aim of this research is to explore the barriers for doctors in the UK when diagnosing and treating advanced cancer patients with VTE.MethodQualitative, in-depth interview study with 45 doctors (30 across Yorkshire, England and 15 across South Wales). Doctors were from three specialties: oncology, palliative medicine and general practice, with a mixture of senior and junior staff. Framework analysis was used.ResultsDoctors opinions as to whether LMWH treatment was ethically appropriate for patients who were symptomatic from VTE but at end of life existed on a shifting continuum, largely influenced by patient prognosis. A lack of immediate benefit coupled with the discomfort of a daily injection had influenced some doctors not to prescribe LMWH. The point at which LMWH injections should be stopped in patients at the end of life was ambiguous. Some perceived ‘overcaution’ in their own and other clinicians’ treatment of patients. Viewpoints were divergent on whether dying of a PE was considered a “good way to go”. The interventionalism and ethos of palliative medicine was discussed.ConclusionsDecisions are difficult for doctors to make regarding LMWH treatment for advanced cancer patients with VTE. Treatment for this patient group is bounded to the doctors own moral and ethical frameworks.