Decisionmaking in a multidisciplinary changing healthcare environment: Experiences of Australian Bus

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Decision-making in a multi-disciplinary changing
healthcare environment Experiences of Australian
Bush Nurses.

• Mollie Burley
• Centre for Multidiscipline Studies
• Monash University School of Rural Health
• Moe, 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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Darwin
Brisbane
Perth
Sydney
Adelaide
Canberra
Melbourne
Victoria
Hobart
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East Gippsland
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Bush Nursing Context
Bush Nursing Context -1
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Bush Nursing Context - 2

• Advanced practitioners working alone in small
  clinics
• Primary healthcare populations lt500
• 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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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.
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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 Womens 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.
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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 Burley Center for
Multi-disciplinary Studies Monash University
School of Rural Health PO Box 973 MOE Victoria
Australia 3825. mollie.burley_at_med.monash.edu.au