Nurses, information use, and clinical decision making--the real world potential for evidence-based decisions in nursing

Abstract

Nurses have probably always known that their decisions have important implications for patient outcomes. Increasingly, however, they are being cast in the role of active decision makers in healthcare by policy makers and other members of the healthcare team. In the UK, for example, the Chief Nursing Officer recently outlined 10 key tasks for nurses as part of the National Health Service’s modernisation agenda and the breaking down of artificial boundaries between medicine and nursing.1 As well, nurses are expected to access, appraise, and incorporate research evidence into their professional judgment and clinical decision making.2 This active engagement with research evidence is the focus of this paper. We will explore why it is necessary to consider the clinical decision making context when examining the ways in which nurses engage with research based information. We will also consider the relation between the accessibility and usefulness of information from different sources and the decisions to which such information is applied. Finally, we will argue that if we are to encourage nurses to actively engage with research evidence during clinical decision making, we need to better understand the relation between the decisions that nurses make and the knowledge that informs them.

In this paper, we draw heavily on the findings of 2 major studies conducted at the University of York between 1997 and 2002.3–9 2 case studies were conducted in 3 geographical areas with different hospital types, population characteristics, and levels of health service provision. We purposively sampled participants according to a sampling frame constructed around variables deemed to be theoretically significant for clinical decision making.7 Data collection comprised 200 indepth interviews with nurses and managers; 400 hours of non-participant observation of “decision making and information use in action”; 4000 practice based documents audited for characteristics such as …

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Nurses, information use, and clinical decision making—the real
world potential for evidence-based decisions in nursing
Nurses have probably always known that their decisions
have important implications for patient outcomes.
Increasingly, however, they are being cast in the role
of active decision makers in healthcare by policy makers and
other members of the healthcare team. In the UK, for example,
the Chief Nursing Officer recently outlined 10 key tasks for
nurses as part of the National Health Service’s modernisa-
tion agenda and the breaking down of artificial boundaries
between medicine and nursing.
1
As well, nurses are expected
to access, appraise, and incorporate research evidence into
their professional judgment and clinical decision making.
2
This
active engagement with research evidence is the focus of this
paper. We will explore why it is necessary to consider the
clinical decision making context when examining the ways in
which nurses engage with research based information. We will
also consider the relation between the accessibility and
usefulness of information from different sources and the
decisions to which such information is applied. Finally, we will
argue that if we are to encourage nurses to actively engage
with research evidence during clinical decision making, we
need to better understand the relation between the decisions
that nurses make and the knowledge that informs them.
METHODS UNDERPINNING THIS PAPER
In this paper, we draw heavily on the findings of 2 major
studies conducted at the University of York between 1997
and 2002.
329
2 case studies were conducted in 3 geographical
areas with different hospital types, population characteristics,
and levels of health service provision. We purposively sampled
participants according to a sampling frame constructed around
variables deemed to be theoretically significant for clinical
decision making.
7
Data collection comprised 200 indepth
interviews with nurses and managers; 400 hours of non-
participant observation of ‘‘decision making and information
use in action’’; 4000 practice based documents audited for
characteristics such as age, research basis, authorship, etc; and
statistically modelled (using the Q methodology approach)
10
perspectives on the accessibility, usefulness, and barriers to use
of information sources from 242 nurses.
EVIDENCE-BASED DECISION MAKING INVOLVES
ACTIVELY USING INFORMATION
Evidence-based decision making involves combining the know-
ledge arising from one’s clinical expertise, patient preferences,
and research evidence within the context of available
resources.
11
Evidence-based decision making—like all decision
making—involves choosing from a discrete range of options,
which may include doing nothing or a ‘‘wait and see’’ strategy.
All such choices are informed by an evaluation of available
information: the process of using clinical judgment. In making
evidence-based decisions, research evidence should not be
taken at face value and adhered to uncritically, but should be
given an appropriate weight in a decision depending on its
internal and external validity. Integrating research evidence
into decision making involves forming a focused clinical
question in response to a recognised information need, searching
for the most appropriate evidence to meet that need, critically
appraising the retrieved evidence, incorporating the evidence into
a strategy for action, and evaluating the effects of any decisions
and actions taken. These steps are important components of
the active process that is evidence-based decision making.
Evidence-based decision making is a prescriptive approach to
making choices, which is based on ideas of how theory can be
used to improve real world decision making. However, before
we plan a strategy to attain this ideal, it is important to
identify our starting point: how do nurses currently use (and
view) research based information in decision making? Surprisingly,
little research has been done on this topic, except for studies
that use self report data from nurses as a source of evidence.
We reject self report as the main source of evidence for
answering our questions in favour of ‘‘real time’’ clinical
observation and indepth interviews, which we feel better
reflect actual types and frequencies of different decisions and
observed information use.
INFORMATION NEED, ‘‘INFORMATION
BEHAVIOUR,’’ AND CLINICAL DECISION MAKING
One of the challenges of researching how people respond to
information deficits is that such deficits, or information needs,
are unobservable. ‘‘Information need’’ is a construct that
exists only in the mind of the person ‘‘in need.’’
12
Researchers
can only hypothesise about the likely needs of nurses based
on what they say, what we can deduce from watching their
behaviour, or preferably both. ‘‘Need’’ cannot be separated
from the motives of information seeking behaviour. If an
information need is to be converted into action (eg, reading
Evidence-Based Nursing or accessing the Cochrane Library), then
individuals must have a motive for doing so. In developing
motives, individuals draw on personal frameworks of beliefs
and values, which contain objects that have satisfied infor-
mation needs in the past. Some objects (eg, MEDLINE) may
be valued less than others (eg, knowledgeable colleagues)
because they previously failed to satisfy information needs.
12
For proponents of evidence-based decision making, the
primary motive for engaging with research based information
is to reduce clinical uncertainty; that is, finding relevant
research will increase one’s certainty that a particular course
of action is most likely to lead to the desired outcomes.
13
However, new information can also elucidate and/or confirm
existing information, beliefs, and values. Nurses often report
that their rationale for seeking research evidence is to support
their existing practice. The processes of searching for,
appraising, and integrating research information with exist-
ing knowledge have been labelled ‘‘information behaviour’’
by some researchers in the field of information science.
14
The types of clinical decisions that nurses actually make
provide clues about how (and what types of) research infor-
mation might assist in decision making. Other authors have
examined the clinical decisions of healthcare professionals
(and the clinical questions arising from such decisions) as
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expressions of potential information need.
15
Thus, decisions
are an important context for information use. We will show
how understanding the structure and characteristics of the
decisions nurses face is important for understanding the ways
in which information is accessed and processed by nurses.
NURSES’ CLINICAL DECISIONS: A TYPOLOGY
The table provides a typology of clinical decisions, with
examples that were derived from interviews with, and
observation of, acute and primary care nurses.
329
These
decisions represent core choices that are only part of the
architecture of the decision making context for applying
research knowledge. Nurses described several other elements
of their clinical decisions and decision making processes.
Frequency of decision making
The number and types of decisions faced by nurses are related
to the work environment, perceptions of their clinical role,
operational autonomy, and the degree to which they see
themselves as active and influential decision makers. Nurses
working on a busy medical admissions unit admitting 50
patients per day face a different set of decision challenges
compared with health visitors (HVs) or public health nurses,
who may see 10 patients per day. Consider the extent to which
judgment and choices feature in this HV’s consultation:
‘‘She was breast-feeding but had very sore cracked and
bleeding nipples on her left breast and she did not know
what to do about it. [What did the HV think?The mother
asked] The HV thought and replied that she had not come
across this problem before, but asked if it was painful.
Mum said that it was and she had tried to feed her from
this breast but it was so painful that she had not done so.
She had only fed from the right breast and for the past
three evenings the baby had fed continuously for six hours
and then slept all night. Someone had suggested using
Camillosan cream for her cracked nipples but it had not
helped at all. However she knew that chamomile was a
relaxant and maybe that was why the baby had slept for so
long the last three nights. The HV mentioned a nipple shield
but said that she had no experience of using them. The mum
said that she wondered if she should just stop feeding from
that breast altogether until they had healed, to which the HV
agreed. The HV then said that if she was having pain in her
breast, that could indicate that she had a thrush infection on
her breast. She then asked if she had seen any white
patches on the baby’s tongue or in her mouth and mum
replied that she had not. No more was said about that.
They agreed that mum would not feed from her left breast
and only use her right until it healed up. The HV said that as
the baby was feeding well from her right breast then that
was OK.’’ (Field notes, health visitor).
This quote illustrates at least 5 judgment or decision
challenges for the HV, all of which generate potential
information needs: (1) ascertain the likely causes of sore
and cracked nipples; (2) choose a management strategy in
the context of little or no experiential knowledge; (3) judge
whether the baby is getting sufficient breast milk; (4) choose
between the merits of Camillosan, Chamomile, or a nipple
shield; and (5) identify the cause of pain (possibly thrush).
Decisional complexity
Three elements of decisional complexity that permeated
nurses’ accounts of their decisions are described below.
Time limited decision making activity. Nurses des-
cribed situations in which rapid decisions were expected (a
phenomenon known as implied response time).
16
Consequently,
Decision types and clinical questions/choices expressed by acute and primary care nurses
Decision type Example of clinical questions/choices
Intervention/effectiveness: decisions that involve choosing among
interventions.
Choosing a mattress for a frail elderly man who has been admitted with an acute
bowel obstruction.
Targeting: a subcategory of intervention/effectiveness decisions
outlined above, of the form ‘‘choosing which patient will benefit most
from the intervention.’’
Deciding which patients should get antiembolic stockings.
Prevention: deciding which intervention is most likely to prevent
occurrence of a particular health state or outcome.
Choosing which management strategy is most likely to prevent recurrence of a
healed leg ulcer.
Timing: choosing the best time to deploy the intervention. Choosing a time to begin asthma education for newly diagnosed patients with
asthma.
Referral: choosing to whom a patient’s diagnosis or management
should be referred.
Choosing that a patient’s leg ulcer is arterial rather than venous and merits medical
rather than nursing management in the community.
Communication: choosing ways of delivering information to and receiving
information from patients, families, or colleagues. Sometimes these
decisions are specifically related to the communication of risks and
benefits of different interventions or prognostic categories.
Choosing how to approach cardiac rehabilitation with an elderly patient who has
had an acute myocardial infarction and lives alone, with her family nearby.
Service organisation, delivery, and management: these types of decisions
concern the configuration or processes of service delivery.
Choosing how to organise handover so that communication is most effective.
Assessment: deciding that an assessment is required and/or what mode
of assessment to use.
Deciding to use the Edinburgh Postnatal Depression screening tool.
Diagnosis: classifying signs and symptoms as a basis for a management
or treatment strategy.
Deciding whether thrush or another cause is the reason for a woman’s sore and
cracked nipples.
Information seeking: the choice to seek (or not to seek) further information
before making a further clinical decision.
Deciding that a guideline for monitoring patients who have had their ACE inhibitor
dosage adjusted may be of use, but choosing not to use it before asking a
colleague.
Experiential, understanding, or hermeneutic: relates to the interpretation
of cues in the process of care.
Choosing how to reassure a patient who is worried about cardiac arrest after
witnessing another patient arresting.
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opportunities for seeking information beyond what was
readily available were perceived as severely restricted.
Limited time was a primary reason for the ‘‘separation’’ of
day to day decision making from information seeking and
appraisal. Despite these constraints on information use, some
nurses felt that as their expertise developed, they managed to
reduce contact time with patients by virtue of having to spend
less time seeking information to reduce uncertainty in
decision making. Decision related information seeking was
associated with novice rather than expert performance.
Multiple and diverse decision goals. The stepwise
nature of information gathering and decision making in
patient encounters, as well as the need to foster patient
perceptions of trust and credibility in the nurse, meant that
decisions often had multiple and conflicting decision goals.
For example, one HV described the need to build confidence
in a young mother, leading her to sanction weaning at 12
weeks rather than (for her) the more optimal 16 weeks
(current best evidence suggests that the optimum time for
weaning is 24 weeks).
17
Conflicting decision elements. As well as making
decisions more complex, conflict can also simplify decisions.
The following example of conflict in nurse-doctor power
relations demonstrates this point:
‘‘When S came back she cleaned the patient’s left leg with
gauze soaked in saline and then applied a dressing
(Jelonet). She said that she felt Jelonet was not ideal but the
patient’s consultant preferred it despite the fact that ‘when
you take it off you are removing the good tissue as well.’
Even if I change the dressing, when the patient goes to the
outpatients’ department and sees the consultant they will
come back with Jelonet and clear instructions that we are
to use Jelonet.’’ (Field notes, district nurse)
THE COGNITIVE CONTINUUM: THE DECISION AS
DRIVER FOR INFORMATION BEHAVIOUR
Since the 1960s, cognitive psychologists and decision
theorists have developed the idea of the cognitive conti-
nuum.
16 18
This model suggests that the major determinants
of whether a person engages in intuitive decision making (ie,
less likely to engage in evidence-based decision making) or
rational decision making (ie, more likely to engage in
evidence-based decision making) depends on where a
decision ‘‘task,’’ such as selecting a nursing intervention,
lies on a (cognitive) continuum (figure). This cognitive
continuum has 3 dimensions,
16 19
which are described below.
Complexity of the task: the number of information cues
(the more cues required for a decision, the more likely it is
that nurses will fall back on intuitive reasoning); the number
of judgment ‘‘steps’’ required to make a choice (eg, selecting
interventions for patients with chronic and comorbid condi-
tions and a lack of complete information readily available)
Ambiguity of the task: the task characteristics that
induce rational information processing include the presence of
easily available (cognitively) organising principles for collect-
ing and handling information and simplifying decisions
(known as feedforward)
20
; a familiar decision task with familiar
content; the presence of an observable outcome for the task;
and a degree of feedback on the likely success of the task. An
example of a task that is more likely to induce rational pro-
cessing (and draw on knowledge derived from research) is the
assessment and treatment of chronic venous leg ulcers. Nurses
assessing and treating leg ulcers identified the helpful role of
the UK Royal College of Nursing Guidelines
21
in collecting the
information required for a good assessment and decision, and
the design of training, audit, and feedback around the
guidelines and decision making in leg ulcer care.
Form of task presentation: very short time frames for
exercising judgment are more likely to induce intuitive
information handling. Alternatively, breaking the task down
into components (decomposition) induces rationality in
handling clinical information, as do information cues that
are dichotomous or discrete (eg, ‘‘this Doppler reading
indicates either venous or arterial aetiology’’); similarly, the
greater the need to make a decision ‘‘visible’’ to others, the
greater the use of analytic reasoning.
The relative balance in the mixture of intuition- and
rationality-inducing task elements predicts the end of the
continuum to which cognition is drawn. Correctly ‘‘matching’’
information and the ways that it is processed (ie, using
more systematic, rational methods rather than intuition)
to the nature of decision tasks results in better decision
performance.
18
Knowledge of a decision task alone, however, is not a
sufficient basis for predicting whether a person will use analy-
tic or intuitive reasoning, or indeed, whether they will even
gather the information necessary to engage in analytic reason-
ing. Consider, for example, a primary care nurse who ignores
the physical presence of a guideline during a consultation in
favour of the more easily accessed (cognitively) knowledge of
one’s own memory and the advice of a colleague.
THE REALITY OF INFORMATION BEHAVIOUR
2 broad patterns of engagement among nurses, research
based information, and clinical decision and judgment tasks
were present in the studies.
Preference for humans as information sources
Both primary and acute care nurses were characterised by
reliance on human sources of information as the primary
means of informing situations in which they were uncertain.
5
We identified 7 distinct perspectives on accessibility, all of
which stress the relative accessibility of experiential sources
of information, such as clinical nurse specialists (CNSs),
experienced colleagues, and other primary and secondary
care team colleagues. Notable exceptions were local protocols
and guidelines in acute care (particularly in areas such as
The cognitive continuum.
Reproduced with permission from Hamm RM. Clinical intuition and
clinical analysis: expertise and the cognitive continuum. In Dowie J,
Elstein A, editors. Professional judgement: a reader in clinical decision
making. Cambridge: Cambridge University Press, 1988:87.
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coronary care) and sources of drug related information, such
as the British National Formulary, drug information sheets,
and pharmacists in primary care. Even when textual
information was seen as accessible, human sources of
information were highly rated in terms of their accessibility.
We also found that simple demographic or biographical
variables, such as clinical experience, educational attainment,
or role on the primary care team, were weak predictors of
perspectives of accessible information sources.
The scale of the relative lack of engagement with
information sources can be gleaned from our observational
data. During 90 hours of observing district nurses in practice,
we found that use of an information source while actually
making a decision in the presence of a patient occurred only
once, in the form of a telephone call to another clinician.
Similarly, in acute care, 180 hours of observation (circa 1080
decisions) revealed only 2 forms of text based information
used ‘‘in action:’’ local protocols or guidelines (used 4 times)
and the British National Formulary (used 50 times).
It would be wrong to infer, however, that research based
knowledge has no part in nurses’ decision making. Rather,
nurses chose not to use the systematic search-appraise-
implement cycle of evidence-based decision making in real-
time for real clinical decisions with rapid implied response
times. Nurses accessed ‘‘evidence-based’’ information
sources—if they accessed them at all—in contexts other
than immediate decision making environments. Nurses
described contact with research based information sources
in the context of continuing professional development and
formal education or training. Other influences included being
involved in the production of local protocols and guidelines
and having to make sense of research such as clinical trials,
or using research evidence to help resolve conflict between
colleagues. Perceptions about the relative accessibility of
human sources of information were mirrored when we asked
nurses about the usefulness of different sources of information
for clinical decision making.
Useful information sources are grounded in clinical
reality
As with accessibility, we identified several important
perspectives on the relative usefulness of different sources
of information for clinical decision making. Each of these
perspectives stressed the usefulness of sources that were
based on experience rather than research. Colleagues, other
members of the primary care team, or senior members of the
clinical team were viewed as the most useful (and accessible)
information sources. In acute care, the most useful source of
information across all perspectives was the CNS, who seemed
to embody the characteristics of useful information sources:
directly answered the question posed; seen to be authoritative
and trustworthy; provided (or could potentially provide) a
balance of ‘‘background’’
13
(factual) knowledge as well as
foreground (management) knowledge; provided supportive
and unchallenging information; and had no or minimal
associated need for critical appraisal.
Given these characteristics, it is easy to understand the
appeal of CNSs (or other experience rich sources) as a source
of information. A district nurse described a link nurse
colleague (a nurse who is responsible for a particular area
of knowledge and practice, such as diabetes or wound care,
and is often linked to the work of a CNS):
‘‘They’re (link nurses) specialists in the area that they
cover, what’s the point of reinventing the wheel?Me going
to the library getting all the information and thinking, ‘oh
I’ve done a good job there.’ I can go to them and they’ve
already got it... But it also gives you back up in areas
where, I’m not a specialist... It’s not just a short cut, it’s that
they’re knowledgeable. They have the information there.’’
(District nurse)
As with perceptions of accessibility, we found that demogra-
phic and biographic variables, such as age, clinical experience,
and levels of educational attainment, were poor predictors of
how useful an information source would be to a nurse.
DECISION MAKING AND MODELS FOR THE
IMPLEMENTATION OF RESEARCH KNOWLEDGE
Many theoretical models of research utilisation implicitly
recognise the importance of decision making as a vital step in
the process of converting knowledge into action. Despite this
implicit recognition, most models fail to account for the
relation between decision characteristics, information use,
and information processing. For example, Lomas
22 23
has
proposed a coordinated model of research implementation,
which proposes that one end point of knowledge diffusion is
negotiating the application of research findings with patients
during the course of clinical practice. In other works, Lomas
also calls for researchers and decision makers to have
increased levels of understanding of each other’s worlds if
research and policy (or practice) are to be better linked.
23
We
would argue that although clinicians are making efforts to
understand research (through initiatives such as critical
appraisal training or, indeed, by reading journals such as
Evidence-Based Nursing), researchers and disseminators often
fail to fully understand the decisions to which their products
are being applied. In relation to organisational policy
decisions, Lomas suggests that researchers should endeavour
to understand the institutional structures for decision
making, the values (expressed as ideologies, beliefs, and
interests), and the fact that there are often multiple
producers of ‘‘evidence’’ (ie, information that actually gets
used for decision making) existing within organisations.
23
Other theorists who have attempted to build ‘‘context’’ into
models of research utilisation also neglect the ‘‘micro’’
context of the actual decisions: their type, the time available,
their perceived complexity, the amount of supporting (or
challenging) information available, and the presence (or
absence) of organising principles for this information.
24
Some researchers have used clinical questions generated by
clinical decisions as expressions of (potential) information
need.
6
15 25
We would argue that researchers need to delve
deeper and begin to develop research exploring the relation
between the information needs such questions represent and
information behaviour by nurses. Moreover, we need to
recognise that simply mapping the core choice at the heart of
a decision (such as whether it arises from uncertainty about a
diagnosis, treatment, or prognosis) is a necessary but
insufficient condition for determining whether information
is deemed relevant or rejected as irrelevant.
Thus far, we have focused on the links between informa-
tion behaviour and clinical decision making from a research-
er’s perspective. It is important to recognise that the
strategies available to clinical decision makers can also alter
their relation with information. Using the principles of the
cognitive continuum, it is possible to simplify decisions by
removing some of their complexity in an effort to induce
individuals to apply ‘‘search and appraisal’’ behaviour. For
example, several nurses recounted the usefulness of a
structured approach to gathering information as a means of
simply gathering the ‘‘important’’ facts when faced with the
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complex judgment task of assessing a patient’s chronic leg
ulcer for venous or arterial aetiology. This structured bundle
of facts (eg, Doppler reading, size, and history) formed the
basis of management decisions that that were sometimes
informed by appropriate national evidence-based guidelines
(albeit often internalised). Similarly, the single area of
decision making in which observable text based information
use was (relatively) common was uncertainty about medica-
tion use. Nurses’ accounts clearly showed that the sources of
information used ‘‘fit’’ the questions that arose from their
decisions—decisions that were often focused and well
structured (eg, should I give this patient drug X or drug Y
to achieve outcome Z?).
This simplification induces shifts towards the rational end
of the continuum. From this perspective, it is easy to imagine
how thinking about the decisions nurses face in clinical
practice might have an impact on their information
behaviour. Indeed, some basic elements of the evidence-
based nursing process could serve to simplify decisions.
Specifically, the development of focused clinical questions
can be conceptualised as a mechanism for removing some of
the ‘‘noise’’ that surrounds choices and help focus attention
on the relevant populations, outcomes, interventions, and the
core type of uncertainty (diagnostic, intervention, or prog-
nostic). Croskery proposes other, slightly more sophisticated,
techniques under the banner of ‘‘cognitive forcing.’’
26
These
techniques involve retraining clinicians to think differently
about problems by accounting for the effects of limited
memory, erroneous perspectives (eg, ignoring base rates of
disease when making diagnoses), limited capacity for self
critique, and poor selection of strategies. The end result is a
heightened sense of meta-cognition or ‘‘thinking about
thinking.’’ Research examining the potential of these types
of approaches to reflection on action is missing in nursing.
CONCLUSION
Nurses are increasingly regarded as key decision makers
within the healthcare team. They are also expected to use the
best available evidence in their judgments and decisions. The
prescriptive model of evidence-based decision making—and
the search-appraise-implement process that accompanies it—
is an active process. Clinicians who want to implement
research in clinical settings sometimes forget that active
information seeking is only one of several possible responses
to the irreducible uncertainties of clinical practice. In fact,
observation of nurses in practice suggests that when ‘‘search
and appraise’’ information behaviour occurs at all, nurses are
far more likely to view colleagues (‘‘human’’ sources of
information) as useful and accessible sources of information
than research in any form. Colleagues are perceived as
delivering context specific, clinically relevant information
that takes into account the needs of the judgment or decision
situation and requires minimal critical appraisal; and they are
time efficient. We would argue that this implies a degree of
‘‘fit’’ between the decision task and the information
provided, although not necessarily the provision of high
quality (ie, reliable or valid) information. Moreover, long
standing theoretical frameworks explain this lack of fit
between traditional evidence-based sources of research
information and the decisions that nurses’ face.
The cognitive continuum model offers a theoretical basis
for a research agenda that is just emerging in nursing.
Outlining the types of clinical decisions is only a starting
point for this agenda. Future work should attempt to explore
and explain the patterns of information use in decisions for
which far more detailed maps exist. Moreover, there is a need
for high quality development and evaluation of interventions
that target evidence-based information provision at those
individuals most likely to influence professional choices (eg,
CNSs). We feel that such knowledge will add a valuable, and
hitherto missing, dimension to existing models of research
utilisation and knowledge transfer.
CARL THOMPSON, RN, PhD
NICKY CULLUM, RN, PhD
DOROTHY MCCAUGHAN, RN, MSc
TREVOR SHELDON, DSc, FMedSci
PAULINE RAYNOR, RN, HV(cert), PhD
University of York
York, UK
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evidence-based decisions in nursing
the real world potential for−−making Nurses, information use, and clinical decision
Pauline Raynor
Carl Thompson, Nicky Cullum, Dorothy McCaughan, Trevor Sheldon and
doi: 10.1136/ebn.7.3.68
2004 7: 68-72 Evid Based Nurs
http://ebn.bmj.com/content/7/3/68
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