Improving the use of evaluation in health settings: do data support and order of recommendation make a difference?

This study examined two variables associated with nurse decision makers' perceptions of the usefulness of program evaluation. The first variable represented amount of data support for recommendations; the second represented the order of presentation of supporting and nonsupporting recommendations. The sample of New York state nurses reflected two levels of decision makers: Supervised (staff nurses) and supervising (head nurses, supervisors, and directors). Results indicated that experience with decision making and order of presentation affected perceptions of recommendations and sufficiency of information.     

Patient participation in decision making: views of health professionals caring for people with colorectal cancer

Aim. The aim of this study was to explore views on patient participation in decision making, as described by health professionals caring for people with colorectal cancer. Background. Patient participation in health‐care decision making is on the policy agenda at an international level. However, many aspects of cancer care and treatment are complex and it is unclear how health professionals view their role as promoters of patient participation. Design. A qualitative exploratory study. Methods. In depth interviews with 35 health professionals in clinical practice. Data were analysed using thematic content analysis, assisted by a computer software package for analysis of qualitative data (N‐VIVO). Results. Choices in relation to surgical treatment were viewed as limited. Although it was perceived that patients could be more involved in decisions related to adjuvant treatment, providing information on various chemotherapy regimes was challenging. It was acknowledged that patients could be involved in treatment choices but there was far less clarity concerning aspects of physical and psychological care. Age was a factor when determining which patients should be offered treatment choices. Conclusion. The availability and presentation of choices to patients is context specific and tailored to the preferences of individuals. If health professionals focus only on aspects of decision making related to treatment, the potential for shared partnerships with patients in relation to choices about physical and psychological care may be lost. This may be particularly pertinent for nurses and allied professions who engage with patients throughout the illness trajectory. Relevance to clinical practice. Policy makers should arguably appreciate that health professionals have an awareness of current thinking on patient participation, but may find policy recommendations challenging to implement in clinical practice when faced with the individual needs and preferences of patients and the complexities and uncertainties of disease management.     

Difference in reported pre-morbid health-related quality of life between ARDS survivors and their substitute decision makers

Context Substitute decision makers may consider the pre-morbid health status of their critically ill loved one when making treatment decisions on her/his behalf.Objective To compare estimates of pre-morbid health-related quality of life (HRQOL) obtained from survivors of the acute respiratory distress syndrome (ARDS) with those of their substitute decision makers using the Short Form 36 (SF-36).Design Prospective cohort study.Setting University-affiliated intensive care unit in Toronto, Canada.Patients A sample of 46 ARDS survivors and their substitute decision makers drawn from a previously described cohort.Interventions We measured agreement and differences between responses on the SF-36 obtained from survivors (at 3 months after ICU discharge) and their substitute decision makers (at study entry).Measurements and results Agreement was poor for all SF-36 components and differences reached significance in three domains. In multivariable analysis considering age; sex; Acute Physiology, Age, and Chronic Health Evaluation II score; and Lung Injury Score, only patient age was associated with the mean difference between estimates for the ‘Mental Health’ domain. On average, estimates of pre-morbid HRQOL obtained from substitute decision makers were lower than those obtained from survivors.Conclusion Agreement between estimates of pre-morbid HRQOL provided by ARDS survivors and their substitute decision makers was poor. Compared with survivors, proxies tended to provide lower estimates of pre-morbid HRQOL. Substitute decision making for incapacitated patients is an imperfect process during which family members may underestimate their loved ones' own perception of pre-morbid health status. Alternatively, survivors of critical illness may overestimate pre-morbid HRQOL.This article is discussed in the editorial available at:     

Bringing health services research to (and from) critical care

Health services research has the potential to improve the care provided to patients in critical care settings by informing the decisions of managers and policy makers who establish many of the rules within which critical care is provided. Living up to this potential requires health services researchers in critical care to enhance the relevance of their research for managerial and policy decision makers and to undertake initiatives to increase the uptake of this research by these decision makers. Researchers can begin by asking questions from the perspective of managers and policy makers, not just from the perspective of patients and clinicians. Researchers can also design studies that will generate valid and generalizable research findings that can be acted on by these decision makers, not just studies that describe a problem or test new methods to describe a problem. Health services research is, after all, an applied field. But researchers may not want to stop there: they can engage in coordinated efforts to facilitate the uptake of their re-search findings, and do so by drawing on our evolving understanding of what works best with these decision makers. Opportunities such as the relaunch of a journal that takes seriously the challenge of informing decision making do not come along often. We hope researchers will rise to the challenge. Copyright © 2002 by W.B. Saunders Company     

Improving the US health care system: action plan to enhance efficiency, reduce errors, and improve quality.

The decisions made by stakeholders in the nation's health care system that affect the quality of care experienced by patients are too often made without the benefit of scientific evidence. A multidisciplinary set of investigators conducting health services research have traditionally filled this gap between research findings and clinical decision making, but several barriers are hindering this work. This article offers several recommendations-restructuring organizations, ensuring funding, developing infrastructure, strengthening the community of researchers, and forging new links among stakeholders-to promote high-quality information for health decision makers.     

Problems in the decision making process: a review

Decision making is an integral part of the intensive care nurse's role, but many factors can disrupt this process. It is important that the nurse has an understanding of how defective decision making patterns can develop. Experience, the role of the nurse, uncertainty and conflict all exert major influences on the decision making process. The conditions that determine what type of decision making pattern emerges are; the seriousness of the risks as a result of the decision; if there is hope of finding a better solution; and how much time is available to search for the solution. The patterns that may emerge include vigilance, complacency, defensive avoidance and hypervigilance. Vigilance is said to be the optimum pattern, this is when all alternatives to the decision are analysed and interpreted in an unbiased manner. Defensive avoidance is the decision makers attempt to avoid or postpone the stress of the decision. It is manifested by procrastination, shifting of responsiblity or rationalisation. Hypervigilance, or panic, represents a frantic search for a solution and a shifting back and forth between alternatives with a failure to see obvious faults in the possible solutions.     

Decision analysis in evidence-based decision making

Many real world decisions have to be made on a limited evidence base, and clinical decisions are at best problematic. We explored some of the reasons why decision making in health care is so complex, and examined how decision analytic techniques might contribute to problem structuring and to implementation of evidence-based practice. We argued that decision analysis could, to some extent, overcome complexity of decision making by a clear structuring of the problem and a formal analysis of the implications of different decisions. Decision-analytic techniques can guide the management of individual patients or can be used to address policy questions about the use of treatment for groups of patients. However, decision analysis is not without its criticisms, e.g. problems are narrowly defined, replacing judgement and dehumanizing care, neglect of process utility and lack of primary data to develop decision analytic models. The development of evidence-based guidelines is a key component of the UK Government's quality strategy led by the National Institute for Clinical Excellence (NICE). However, the guidelines approach may lead to conflict when assessments of the effectiveness of interventions for individuals (whether or not supported by a formal decision analysis) conflict with the recommendations made by NICE for cost and clinical effectiveness for aggregate groups of patients. Decision analysis may or may not help with this but if guidelines are derived from a decision analysis, then the implications of patient preferences should be made clearer. However, decision analysis-derived guidelines will make general recommendations that may not be appropriate for all individuals. Nonetheless, decision analysis does make such implications explicit and propose that the guidelines should be supported by some mechanism for determining individual patient preferences. It will now need to consider whether some of NICE resources should be directed beyond evidence-based guidelines into decision analysis-derived guidelines and into decision analytical techniques to provide support for clinical and cost effective decision making within the patient-clinician encounter.     

Undermedication for pain: an ethical model.

Ethical decision making for, and with, clients experiencing pain and needing narcotic analgesia is especially problematic as evidenced by research findings. This article demonstrates the application of Greipp's model to ethical decision making for clients experiencing pain. Particular attention within this model is given to learned potential inhibitors of the nurse as they influence the outcome (decision). The application of this model to decision making and pain management will generate further scientific inquiry by identifying the areas of breakdown in ethical decision making for and by clients experiencing pain so that remediation strategies may be planned.     

Decisional conflict and regret: Consequences of surrogate decision making for the chronically critically ill

Decisional conflict may predispose surrogate decision makers (SDMs) of the chronically critically ill (CCI) to making health care decisions that are not aligned with the patient's health care preferences and increase the SDM's likelihood of experiencing decision regret. This study establishes the relationship between decisional conflict and decision regret and offers insight on tailoring decision support interventions to the preferences of SDMs of CCI patients.     

循证卫生决策研究方法介绍

循证决策是卫生决策者最常用的、客观的、也是最重要的一种卫生政策研究方法。其目的是改变传统的主观臆断卫生决策,促进卫生政策和系统研究知识的应用与传播,以改进国家和地区卫生系统的绩效。影响循证卫生决策效果的三个要素是：研究证据,可利用的卫生资源以及政策的价值取向。本文介绍了一些实用的循证决策方法,特别是系统评价、优先重点的选择和CAM矩阵分析方法。     

Implications for Australian practice of North American guidelines for the support of the family in patient-centred intensive care

Patient-centred care, in which health care professionals inform patients and families, maintain active involvement in decision making, coordinate care across disciplines, provide families with physical comfort and emotional support and ensure care is culturally sensitive, is recommended over clinician- or disease-centred care for better patient outcomes. Patients in intensive care are often too ill to participate in communication and decision making, so the patient's family should be involved in communication and decision making about the patient's care. The Society of Critical Care Medicine published clinical practice guidelines for the support of the family in the patient-centred intensive care unit. The purpose of this paper is to assess whether the 42 recommendations in the guidelines are valid and applicable in Australia. We used a recognised framework for evaluation of clinical practice guidelines. It was found that the guidelines were developed systematically using accepted methods of guideline development as much as possible. An extensive literature review was conducted and publications containing all levels of evidence were considered for inclusion. There were some weaknesses in the guideline development, especially lack of consultation with patients and families and a lack of high-level evidence, however the authors have provided comprehensive recommendations to guide all aspects of patient-centred care. We conclude that the recommendations are largely applicable to the patients and families receiving treatment and support within intensive care units in Australia. Where strong evidence is lacking, the recommendations should be a stimulus to conduct studies that test interventions that may benefit intensive care patients, their families, and intensive care staff.     

Multi-criteria clinical decision support: A primer on the use of multiple criteria decision making methods to promote evidence-based, patient-centered healthcare

Current models of healthcare quality recommend that patient management decisions be evidence-based and patient-centered. Evidence-based decisions require a thorough understanding of current information regarding the natural history of disease and the anticipated outcomes of different management options. Patient-centered decisions incorporate patient preferences, values, and unique personal circumstances into the decision making process and actively involve both patients along with health care providers as much as possible. Fundamentally, therefore, evidence-based, patient-centered decisions are multi-dimensional and typically involve multiple decision makers.Advances in the decision sciences have led to the development of a number of multiple criteria decision making methods. These multi-criteria methods are designed to help people make better choices when faced with complex decisions involving several dimensions. They are especially helpful when there is a need to combine "hard data" with subjective preferences, to make trade-offs between desired outcomes, and to involve multiple decision makers. Evidence-based, patient-centered clinical decision making has all of these characteristics. This close match suggests that clinical decision support systems based on multi-criteria decision making techniques have the potential to enable patients and providers to carry out the tasks required to implement evidence-based, patient-centered care effectively and efficiently in clinical settings.The goal of this paper is to give readers a general introduction to the range of multi-criteria methods available and show how they could be used to support clinical decision-making. Methods discussed include the balance sheet, the even swap method, ordinal ranking methods, direct weighting methods, multi-attribute decision analysis, and the analytic hierarchy process (AHP).     

RXPERT: a prototype expert system for formulary decision making.

OBJECTIVE: RXPERT, a prototype, computer-based, expert system that models the decision-making processes for an ambulatory (non-hospital) formulary, is described as an example of how expert systems may be used to support pharmacy decision making. Basic information about expert-system technology is provided through this example. BACKGROUND: Computer-assisted decision making is becoming an important and accepted aspect of complex, health-related decisions. Because expert-system support may become an integral component of future, complex, pharmacy decision making, it is important for pharmacists to become familiar with this technology and its possibilities for supporting pharmacy decisions. METHOD: Expert systems offer the potential advantages of making the human decision-making process explicit, more consistent, easily duplicated in many locations simultaneously, and easy to update and document. Although an expert system is seldom intended to replace human decision makers, it can provide valuable support for complex, multivariable decisions. Typical knowledge-acquisition and knowledge-engineering techniques, as well as the characteristics and structure of expert systems, are described, relative to the development of the RXPERT prototype. CONCLUSIONS: Although RXPERT is not yet in use, the process for using an expert system to support an individual committee member's personal assessment of a drug product is described. Decision-support expert systems are potentially useful to pharmacists in complex decision-making tasks.     

Review of Controversial Areas in Anaphylaxis for the Nurse Practitioner

Anaphylaxis is a systemic, potentially fatal allergic reaction that can occur without warning after exposure to allergens including food, drugs, and insect venom. This article focuses on controversial issues in anaphylaxis management for the nurse practitioner in primary care. In instances in which clinical recommendations may not be available, a best practice approach based on reported evidence, case experience, and clinical logic should be used to guide decision making.     

Percutaneous endoscopic gastrostomy (PEG): the role and perspective of nurses

Aims and objectives. To study the perspectives of nurses on (i) the process of decision‐making regarding the placement of feeding gastrostomies, (ii) their role in the process, (iii) the impact this participation has on them personally and (iv) gastrostomy placement in general. Background. The decision to commit patients to long‐term feeding using a gastrostomy tube can be very difficult, particularly when the anticipated benefits are uncertain. Strategies to improve such decision‐making are required. Nurses are in an excellent position to provide valuable insights regarding this decision‐making and their increased participation in this process might substantially improve it. Design. A cross‐sectional, exploratory design using in‐depth semi‐structured interviews and a self‐administered questionnaire. Methods. In‐depth semi‐structured interviews with 17 nurses experienced in percutaneous endoscopic gastrostomy decision‐making were undertaken and analysed. Results. Individuals making decisions regarding feeding gastrostomy placement were observed to be insufficiently informed regarding the device and the ramifications of its placement. Nurses were perceived to play an important, although underused, role in decisions to commit patients to long‐term feeding. Participation in the making of these decisions may be stressful to nurses, particularly when the only result anticipated is the sustaining of a life of poor quality. Sixteen nurses reported that they would not want to have a gastrostomy for themselves if they were unable to maintain some quality of life. Strategies that could improve decision‐making were suggested. Conclusions. Decision‐making could be improved by providing better information to decision makers. A team‐orientated approach and more active dialogue with regard to care planning among health professionals, especially between doctors and nurses is needed. Effective decisions regarding feeding gastrostomy placement require adequate resources, especially sufficient time for caregivers to communicate effectively with those who must make these decisions. Relevance to clinical practice. The role of nurses in decision‐making regarding commitments to long‐term feeding using gastrostomy tubes could be effectively augmented.     

Ethical decisions in fetal medicine and neonatal intensive care

The Nuffield Council on Bioethics (2006) report Critical Care Decisions in Fetal and Neonatal Medicine: Ethical issues addressed three areas of concern to professionals and the public: fetal medicine, the borderline of viability, and critical care decision making for babies receiving intensive care. Common principles and initial recommendations for professional practice are presented in the report which is based on wide consultation. While many professionals may feel that the report re-iterates current good practice, it also demonstrates inequity and inconsistency in practice across the country. Royal Colleges and other interested parties need to act to address these inconsistencies and further develop consensus guidelines. The need for transparency in decision making and for a true partnership approach to all aspects of fetal and neonatal care is reaffirmed, with recommendations for action by government and professional bodies as well as by professionals delivering obstetric and neonatal care and their educators.     

Shared decision‐making in mental and behavioural health interventions

Elements of shared decision‐making (ie, collaboration, patient preferences, and working alliance) have long been discussed and studied in the field of clinical psychology; however, research indicates that shared decision‐making is not typically used in clinical practice. Instead, clinicians often rely on a paternalistic approach. In this article, we provide a narrative review of the existing research supporting shared decision‐making for mental and behavioural health concerns, we discuss several barriers that impede its use in actual clinical practice, and we provide recommendations for increasing shared decision‐making when working with patients.     

Use of Personalized Decision Analysis in Decision Making for Palliative vs. Surgical Management of the Oldest-Old Patients With Localized Skin Cancer in a Culturally Sensitive Environment: A Case Study of a 96-Year-Old Male Taiwanese Patient

Clinical management of older cancer patients is challenging, especially for those in the oldest-old age group. In the Chinese culture, the preference toward noninvasive care for patients in this age group may create a difficult situation for clinicians when the cancer is potentially curable. Palliative care may not always be the obvious choice, especially if patients suffer from quality-of-life impairment because of symptoms related to progression of the untreated cancer. Balancing between higher rates of toxicities and potential gains in quality of life from anticancer therapies among the oldest old presents a real challenge in clinical practice. Decision analysis is an analytical tool that has a long history of successful application in clinical decision making. In this case study of a 96-year-old male with localized skin cancer, we demonstrate that personalized decision analysis can be a helpful tool to assist decision making in the clinical management of cancer patients in the oldest-old age group, especially in situations in which the evidence-based literature provides little guidance. This was achieved by providing information to help the key decision makers to better understand the risk-benefit trade offs and make an informed decision. We found that the option of surgical management was associated with higher expected quality-adjusted life years (0.894) than best supportive care (0.853). Based on this finding and various scenarios explored in sensitivity analyses, the family members recommended surgery for the patient. The patient recovered well from surgery and there is no evidence of recurrence to date.     

Dying Tax Free: The Modern Advance Directive and Patients' Financial Values

Advance directives are often used to help patients articulate their end-of-life treatment preferences and guide proxy decision makers in making health care decisions when patients cannot. This case study and commentary puts forth a situation in which a palliative care consultation team encountered a patient with an advance directive that instructed her proxy decision maker to consider estate tax implications when making end-of-life decisions. Following presentation of the case, the authors focus on two ethical issues: 1) the appropriateness of considering patients' financial goals and values in medical decision making and 2) whether certain kinds of patient values should be considered more or less relevant than others as reasons for expressed treatment preferences. Clinicians are encouraged to accept a wide range of patient values as relevant to the clinical decision-making process and to balance the influence of those values with more traditional notions of clinical harm and benefit.     

Six habits to enhance MET performance under stress: A discussion paper reviewing team mechanisms for improved patient outcomes

Effective team decision making has the potential to improve the quality of health care outcomes. Medical Emergency Teams (METs), a specific type of team led by either critical care nurses or physicians, must respond to and improve the outcomes of deteriorating patients. METs routinely make decisions under conditions of uncertainty and suboptimal care outcomes still occur. In response, the development and use of Shared Mental Models (SMMs), which have been shown to promote higher team performance under stress, may enhance patient outcomes. This discussion paper specifically focuses on the development and use of SMMs in the context of METs. Within this process, the psychological mechanisms promoting enhanced team performance are examined and the utility of this model is discussed through the narrative of six habits applied to MET interactions.A two stage, reciprocal model of both nonanalytic decision making within the acute care environment and analytic decision making during reflective action learning was developed. These habits are explored within the context of a MET, illustrating how applying SMMs and action learning processes may enhance team-based problem solving under stress. Based on this model, we make recommendations to enhance MET decision making under stress. It is suggested that the corresponding habits embedded within this model could be imparted to MET members and tested by health care researchers to assess the efficacy of this integrated decision making approach in respect to enhanced team performance and patient outcomes.