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.