www.monash.edu.au decision-making in a multi-disciplinary changing healthcare environment:...
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Decision-making in a multi-disciplinary Decision-making in a multi-disciplinary changing healthcare environment: changing healthcare environment: Experiences of Australian Bush Nurses.Experiences of Australian Bush Nurses.
Mollie BurleyCentre for Multidiscipline StudiesMonash University School of Rural HealthMoe, Victoria, Australia
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Presentation overview.
• Bush nursing:
– Context & role
• Decision-making:
– Types of knowledge & knowing
– Theories
– Bush nurses lived experiences
• Blurring the boundaries
• Findings
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AUSTRALIA
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Brisbane
Sydney
Hobart
AdelaideCanberra
MelbourneVictoria
Darwin
Perth
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East Gippsland
VICTORIAAUSTRALIA
Bairnsdale
Melbourne
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Cann Rv
EAST GIPPSLANDVICTORIA AUS
Swifts CK
BuchanDargo
Gelantipy
Bairnsdale
Moe
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Bush Nursing Context:
BNC Kms: Regional
H/S
Time:
Regional H/S
Time Major Referral H/S
Major Metro: Specialists
A 75 1.0 hr 2.3 hrs 4.0 hrs
B 91 1.45 hrs 3.15 hrs 4.45 hrs
C 100 1.30 hrs 3.0 hrs 5.3 hrs
D 114 1.40 hrs 3.10 hrs 5.4 hrs
E 163 2.0 hrs 3.5 hrs 5.0 hrs
Bush Nursing Context -1:
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Bush Nursing Context - 2:
• Advanced practitioners working alone in small
clinics
• Primary healthcare – populations <500
• Telephone access - advice & support
• Local resources:
– volunteer ambulance officers
– Police & State Emergency Service backup
• Complex decision-making required
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Decision-making.
Complexity:• Uncertain & unstable healthcare
environments• Rapid pace of change• More informed consumers• Higher expectations• Higher client acuity• Demands for efficiency, effectiveness
and rationale for decision-making
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Majority of nursing decisions:
• Intervention:
– Modify the situation
• Communication:
– Give or receive information
• Evaluation:
– Review/evaluate client data
– Determine current health status
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Key decision theories.
• Systematic or analytical – information processing theory
– Theoretical / empirical evidence ie: transparent
– Hypothesis confirmed or refuted
– Decision system into short & long term memory
– Bayesian logic
• Intuitive – humanistic theory– Lack of consensus about intuition
– Intuition/expertise ie: invisible
– Context/domain-specific
– Heuristics “rules of thumb”
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Cognitive Continuum Theory.
• ‘Middle ground’ between Intuition and Analysis
• Neither analytical nor intuitive framework explains practice decisions
• Involves modes of cognition determined by:– Structure of task
– Time available for decision
– Number of information cues
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Well structured
↑
TaskCharacteristics
↓
Ill structured
Scientific experiment(Mode 1)
High
↑
Potential for manipulation; visibility; time
required
↓
Low
Controlled trials(Mode 2)
Quasi-experimental(Mode 3)
System-aided judgment(Mode 4)
Peer-aided judgment(Mode 5)
Intuitive judgment(Mode 6)
INTUITION ← Mode of cognition → ANALYSIS
Short time/ ← Time frame & control → Long time/Low control High control
Cognitive Continuum Theory: 6 models of enquiry/practice, adapted from Hammond 1988. HARBISON, J. (2001) Clinical decision making in nursing: theoretical perspectives & their relevance to practice. Journal of Advanced Nursing, 35, 126-133.
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Types of knowledge.
PropositionalKnowledge
PersonalKnowledge
ProfessionalCraft Knowledge
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Propositional knowledge: knowing “that”.
• Scientific research to theory• Critical thinking: Hypothesis-deductive
reasoning• Generalised findings• Higher status knowledge• Heuristics – pattern recognition & “rules
of thumb”• Objective knowledge of the field• Public knowledge of the external world
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Professional Craft Knowledge: “knowing how”
• Embedded in practice & creates new knowledge
• Discipline-specific clinical knowledge• Interpretive models eg: Benner (1984)
– Emphasis on social or human services– Client-centered care
• Iceberg theory– 1/10th visible– 9/10ths invisible
• Knowledge – general & specific
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Personal Experience: knowing “how”
• Emancipatory & imaginative knowledge
• Clinician engaged in the interaction
• Result of personal experience & reflection
• Unique frame of reference of “self”
• Understand complex human desires
• Feelings, purposefulness, interpersonal, emotional and spiritual
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Gathering decision-making data:
Integration and re-analysis of data collected for
original study
• Literature review
• Lived experiences of bush nurses – vignettes
– Positive & negative stories from all aspects of
clinical role
• Healthcare professionals survey
– Interaction/s with BN
– Quality of BN decisions
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Lived experiences of BNs.
In a Semi-structured survey bush nurses:
• Reflected on events that had an impact on them/their practice
• Classified experience as positive or negative [No limit on number of responses]
• Documented the event
• 29 responses received
– 15 positive related mainly to clinical
– 14 negative related mainly to relationships
• Child burns example
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Multi-disciplinary collaboration - 1.
• Questionnaire 65 distributed, 38 returned -58.5% return rate
• 14 Doctors, 11 Nurses, 2 Allied Health & 2 other disciplines
• Doctors:
– 11 general practitioners
– 3 specialists
• Nurses:
– 4 Women’s health
– 3 Diabetes
– 1 each from Mental health, community, Drug and Alcohol & Immunization
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Multi-disciplinary collaboration - 2.
• Allied health:– Pharmacist
– Psychologist
• Other disciplines:– 4 Complementary therapists
– 4 Social welfare
– 1 Ambulance
– 1 Pathology
– 1 State Emergency Service
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Reasons for collaboration.
CATEGORY TOTAL DURING HRS
AFTER HRS
Clinical advice 25 19 6
Follow-up 15 15 0
Emergency advice 10 4 6
Referral 7 7 0
Feedback 7 6 1
Peer support 6 6 0
Other 17 13 4
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Blurring the boundaries:
• Advanced primary healthcare practitioners
• Skills in Advanced health assessment, Mental Health First-Aid & Counselling
• Liaise with health professionals & implement treatment/care
• Shared care with a range of clinicians• Multi-disciplinary team participant• Emergency & trauma care
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Conclusion; Bush nurses are …..
Advanced practitioners• Negotiate boundaries - multi-disciplinary
team• Effective decisions• Range of decision-making models• Difficulty articulating:
– decisions &– contribution to care
• Recognition –valued members of multi-disciplinary team
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Contact details:
Mollie BurleyCenter for Multi-disciplinary StudiesMonash University School of Rural HealthPO Box 973MOE Victoria Australia 3825.