Abstract
Nurses are constantly making choices in circumstances of uncertainty. We are never faced with options for care where one of the options is simultaneously the most effective, the quickest to obtain, the cheapest, and the easiest to use. It is likely that the ‘best’ option is one that balances all of these attributes to some extent. If we are to help nurses make decisions that respect patient and family priorities, commissioner imperatives (effectiveness and cost) and clinical concerns (ease of use, availability) then we need to know the relative importance of these various aspects. This would, for example, allow commissioners of care to prioritise the improvements that would make the biggest difference, for example should they prioritise making an intervention (such as support surfaces) available immediately, or a more effective (and expensive one) available quickly (say the next day) rather than immediately.
This paper investigates the relative weighting (importance) that senior community nurses place on the importance of various attributes of a treatment for preventing pressure ulcers. It describes the use of a discrete choice experiment to reveal these weightings in community nurses. This quantitative method reveals the relative weightings for decision making. The attributes themselves are identified via qualitative work, including interviewing and focus groups of relevant informants. It does not capture what nurses actually do, but asks them to make decisions based on scenarios developed (and analysed statistically) to reveal how attributes are weighted.
The study presented 16 scenarios to 124 nurses and they chose treatments based upon the attributes described of the theoretical intervention, namely: ease of treatment, impact of treatment on patient lifestyle, affordability of treatment, strength of current evidence and speed of treatment.
The characteristics of a treatment that made it a ‘preferred option’ in the scenarios were that they were easy to use, affordable, were effective, and were available quickly. Despite interviews indicating that ‘impact of intervention on patient lifestyle’ was described as being important to nurses, this was not seen in the discrete choice experiment. This means that nurses didn’t actually prioritise this aspect OVER the other important factors: when nurses were presented with options where an intervention had ‘less of an impact on patient lifestyle’ but was less effective, less affordable, slower to obtain or was less easy to use, they rejected it.
This prompts questions about the way in which we choose interventions with and for patients. Nurses would, if asked directly, likely note the impact of an intervention on clients as being an important factor. However, this experiment failed to reveal this. It may be that in reality nurses do prioritise ‘impact’ but perhaps the small sample size in this study, or some other methodological issue, such as only addressing single factors instead of interactions between factors meant that this was not observed. Of course, it may be that the interviews are not capturing nurse preferences, for example with desired response biases meaning that nurses state that they prioritise impact on patient lifestyle, when they do not in the harsh reality of clinical decision making.