Information use in clinical practice: A case study of critical care nurses' enteral feeding decisions

Although registered nurses have a plethora of information sources available to assist them in making clinical decisions, how this information informs such decisions is not well understood. Through the work undertaken in this thesis a deeper understanding of information use in clinical practice is developed. Information use in clinical uncertainty is explored, specifically in the context of making decisions about enteral feeding practices within critical care environments. Instrumental case studies were used to access the information use processes of registered nurses working in an intensive care unit. Two case sites (a Level III intensive care unit in metropolitan teaching hospital and a Level II intensive care unit in a district hospital) were selected for the purpose of theoretical replication. Data were collected to inform specific issues. Concurrent verbal protocols (think aloud), observation and retrospective probing were used to explore documented clinical decisions and the information used to inform those decisions. Q sorting was used to determine the accessibility and usefulness of information available to participants and focus groups were used to explore senior nurse clinician’s perceptions of the authority of the identified information sources. A synthesis of findings from the two case sites highlighted three key issues. First, natural testimony (the use of personal communication to obtain information) was privileged over other, more formal sources of information however the veracity of the information obtained through natural testimony was not explicitly assessed. Registered nurses relied on the credibility of the person providing the information, leaving the information itself unchallenged. The clear reliance on information accessed through natural testimony, but the evident lack of critical evaluation of information obtained in this way, indicates a need for the development of strategies for the critical assessment of the accuracy of this clinical information. Second, the findings highlighted nurses’ use of clinical inquiry. Nurses used clinical inquiry to resolve clinical uncertainty as well as for logistic reasons. Participant’s use of inquiry was influenced by their approach to work, the impact of both organisational and personal perspectives on the perceived value of their work; and by models of clinical leadership where an investment in relational capital was considered a strategy to positively influence a culture of inquiry. Although organisational documents which are designed to ensure quality and consistency of patient care as required by current clinical governance strategies were considered useful, these document were not widely used as a primary source of information. The use of organisational documents, as well as the need to practice in concert with such documents, was identified as a factor negatively impacting on the development and support of nurses’ use of clinical inquiry. Third, findings addressed the usefulness of information for clinical decisions and the resolution of clinical uncertainty. The usefulness of information was influenced by its relevance to a clinical question or information deficit, and by the media used to convey the information. In general, print based media was considered more useful than other forms such as electronic documents. While original research was not considered useful, nurses valued research-based practice and responded positively to incorporating research into practice, particularly if research was pre-appraised by colleagues who were able to disseminate research findings to the clinical area and facilitate its use in clinical practice. This case study indicates that information use is less about individuals and the clinical context in which they are making decisions, and more about the social, cultural and organisational influences that shape decision making, and the information selected to support those decisions. The preference for natural testimony as information in decision making may, on first consideration, be viewed as undesirable in a work context that relies on accurate and consistent documentation. Determining the credibility of the information provider and the accuracy of the information itself is also challenging in an environment where this type of information and the approach to accessing it is selected for its ease of accessibility and the speed at which it can be applied. Yet, the pervasiveness with which nurses rely on others for information suggests verbal testimony is important in the context of clinical practice and highlights the need to develop a clearer understanding of why nurses privilege this information. Therefore verbal testimony must be considered carefully as a strategy for providing information, particularly research-based information and this study therefore highlights the need to develop strategies that enable those providing information to convey their expertise as a clinician as well as a user and provider of information. The organisational culture and work structures currently in place in Australia are unlikely to undergo significant change in the coming years, therefore their impact on information use warrants careful consideration. The nursing profession and the higher education sector aim to foster through inquiry, the independent, evidence-based practice of registered nurses. Health care organisations also highly value independent, evidence-based practice but also promote patient safety through use of current clinical governance strategies. While these two goals can be complimentary they also create tension when clinical governance strategies stifle inquiry and independent decision making of registered nurses. Ultimately, the current health care system in Australia and the wider community expect an evidence base for practice together with clinical governance strategies that promote safe practice. Nurses, as part, of this system must be accountable for both in the context of their clinical practice. We therefore need with some urgency to determine how to best balance these complementary and simultaneously competing ideals

Information use in clinical practice: A case study of critical care nurses' enteral feeding decisions

Although registered nurses have a plethora of information sources available to assist them in making clinical decisions, how this information informs such decisions is not well understood. Through the work undertaken in this thesis a deeper understanding of information use in clinical practice is developed. Information use in clinical uncertainty is explored, specifically in the context of making decisions about enteral feeding practices within critical care environments. Instrumental case studies were used to access the information use processes of registered nurses working in an intensive care unit. Two case sites (a Level III intensive care unit in metropolitan teaching hospital and a Level II intensive care unit in a district hospital) were selected for the purpose of theoretical replication. Data were collected to inform specific issues. Concurrent verbal protocols (think aloud), observation and retrospective probing were used to explore documented clinical decisions and the information used to inform those decisions. Q sorting was used to determine the accessibility and usefulness of information available to participants and focus groups were used to explore senior nurse clinician’s perceptions of the authority of the identified information sources. A synthesis of findings from the two case sites highlighted three key issues. First, natural testimony (the use of personal communication to obtain information) was privileged over other, more formal sources of information however the veracity of the information obtained through natural testimony was not explicitly assessed. Registered nurses relied on the credibility of the person providing the information, leaving the information itself unchallenged. The clear reliance on information accessed through natural testimony, but the evident lack of critical evaluation of information obtained in this way, indicates a need for the development of strategies for the critical assessment of the accuracy of this clinical information. Second, the findings highlighted nurses’ use of clinical inquiry. Nurses used clinical inquiry to resolve clinical uncertainty as well as for logistic reasons. Participant’s use of inquiry was influenced by their approach to work, the impact of both organisational and personal perspectives on the perceived value of their work; and by models of clinical leadership where an investment in relational capital was considered a strategy to positively influence a culture of inquiry. Although organisational documents which are designed to ensure quality and consistency of patient care as required by current clinical governance strategies were considered useful, these document were not widely used as a primary source of information. The use of organisational documents, as well as the need to practice in concert with such documents, was identified as a factor negatively impacting on the development and support of nurses’ use of clinical inquiry. Third, findings addressed the usefulness of information for clinical decisions and the resolution of clinical uncertainty. The usefulness of information was influenced by its relevance to a clinical question or information deficit, and by the media used to convey the information. In general, print based media was considered more useful than other forms such as electronic documents. While original research was not considered useful, nurses valued research-based practice and responded positively to incorporating research into practice, particularly if research was pre-appraised by colleagues who were able to disseminate research findings to the clinical area and facilitate its use in clinical practice. This case study indicates that information use is less about individuals and the clinical context in which they are making decisions, and more about the social, cultural and organisational influences that shape decision making, and the information selected to support those decisions. The preference for natural testimony as information in decision making may, on first consideration, be viewed as undesirable in a work context that relies on accurate and consistent documentation. Determining the credibility of the information provider and the accuracy of the information itself is also challenging in an environment where this type of information and the approach to accessing it is selected for its ease of accessibility and the speed at which it can be applied. Yet, the pervasiveness with which nurses rely on others for information suggests verbal testimony is important in the context of clinical practice and highlights the need to develop a clearer understanding of why nurses privilege this information. Therefore verbal testimony must be considered carefully as a strategy for providing information, particularly research-based information and this study therefore highlights the need to develop strategies that enable those providing information to convey their expertise as a clinician as well as a user and provider of information. The organisational culture and work structures currently in place in Australia are unlikely to undergo significant change in the coming years, therefore their impact on information use warrants careful consideration. The nursing profession and the higher education sector aim to foster through inquiry, the independent, evidence-based practice of registered nurses. Health care organisations also highly value independent, evidence-based practice but also promote patient safety through use of current clinical governance strategies. While these two goals can be complimentary they also create tension when clinical governance strategies stifle inquiry and independent decision making of registered nurses. Ultimately, the current health care system in Australia and the wider community expect an evidence base for practice together with clinical governance strategies that promote safe practice. Nurses, as part, of this system must be accountable for both in the context of their clinical practice. We therefore need with some urgency to determine how to best balance these complementary and simultaneously competing ideals

Mental Health Literacy: How to Obtain and Maintain Positive Mental Health

sem resum

Changing practice in dementia care in the community: developing and testing evidence-based interventions, from timely diagnosis to end of life (EVIDEM)

Background Dementia has an enormous impact on the lives of individuals and families, and on health and social services, and this will increase as the population ages. The needs of people with dementia and their carers for information and support are inadequately addressed at all key points in the illness trajectory. Methods The Unit is working specifically on an evaluation of the impact of the Mental Capacity Act 2005, and will develop practice guidance to enhance concordance with the Act. Phase One of the study has involved baseline interviews with practitioners across a wide range of services to establish knowledge and expectations of the Act, and to consider change processes when new policy and legislation are implemented. Findings Phase 1, involving baseline interviews with 115 practitioners, identified variable knowledge and understanding about the principles of the Act. Phase 2 is exploring everyday decision-making by people with memory problems and their carers

The COVID-19 Clinician Cohort (CoCCo) Study: Empirically Grounded Recommendations for Forward-Facing Psychological Care of Frontline Doctors

In this book, we focus on health and wellbeing in the workforce within the context of the global COVID-19 pandemic, and the post-pandemic era. We begin by exploring the impacts of the pandemic on diverse occupational groups, considering the broader mental health impacts of the pandemic, reactions to national lockdowns and behavioural strategies to control the spread of the virus, such as social distancing and self-isolation, attitudes towards infection control and work presenteeism. Next, we explore the relationship between job factors, working conditions and psychological wellbeing of employees. The papers that follow examine changes in work patterns and locations, such as remote, hybrid, and on-site working, the impact of organizational climate on mental wellbeing, and organizational approaches to return-to-work after lockdown. Finally, we present innovative organizational- and individual-level pandemic mitigation interventions, including SARS-CoV-2 testing services and infection control approaches, digital mental health support, and COVID-19 Vaccine Education. This collection demonstrates the breadth of research on work, health and wellbeing, during and beyond the COVID-19 pandemic, covering workforce impacts and workforce interventions in various countries and settings. Learning from this research will help to build global preparedness for future pandemics and foster resilience for responding in times of crisis and uncertainty

Intelligent Systems for Sustainable Person-Centered Healthcare

This open access book establishes a dialog among the medical and intelligent system domains for igniting transition toward a sustainable and cost-effective healthcare. The Person-Centered Care (PCC) positions a person in the center of a healthcare system, instead of defining a patient as a set of diagnoses and treatment episodes. The PCC-based conceptual background triggers enhanced application of Artificial Intelligence, as it dissolves the limits of processing traditional medical data records, clinical tests and surveys. Enhanced knowledge for diagnosing, treatment and rehabilitation is captured and utilized by inclusion of data sources characterizing personal lifestyle, and health literacy, and it involves insights derived from smart ambience and wearables data, community networks, and the caregivers’ feedback. The book discusses intelligent systems and their applications for healthcare data analysis, decision making and process design tasks. The measurement systems and efficiency evaluation models analyze ability of intelligent healthcare system to monitor person health and improving quality of life

Conceptions of effective information use and learning in a tele-health organization: a phenomenographic study of information literacy and knowledge management at work.

This research study investigates the concept of workplace information literacy (IL) theoretically and empirically, focusing on the connections between information literacy and knowledge management (KM). This dissertation examines the relevance and applicability of current IL frameworks in a workplace environment by means of a review of the literature, a review of NHS Scotland documentation on its KM initiatives, and a phenomenographic study undertaken with frontline staff at NHS24, a nurse-led, 24/7 service of NHS Scotland that provides over-the-phone consultation and health information. For that study, a working definition of IL as effective information use was employed. The concept of information literacy has been developed mainly within librarianship, researched mainly within educational contexts and focused on individual competence in information use. While its application to workplace environments has been assumed, comparatively little research has been done into workplace situations. On the other hand, the concept of knowledge management is directed at a wider organizational level. However, while there is a clear focus in the KM literature on the value of information and its importance for organizations, little attention has been paid to the theoretical and empirical developments of Library and Information Science (LIS) relative to information behaviour and effective information use. The findings of this research identified limitations in the current IL frameworks, notably the lack of consideration for peoples exchanges of knowledge and information and of the social sense making that influences information interpretation and application. The findings endorse views of learning and information use grounded in socio-constructive perspectives and a consideration of context as situated practice. The conclusions suggest the need for more collaboration between studies of IL and information behaviour, and for LIS research to focus more on workplace studies and knowledge management