The American Academy of Nursing (AAN) recently announced that it has joined the ABIM Choosing Wisely campaign with a list that focuses specifically on nursing interventions or practices that are not supported by evidence. The list is called Five Things Nurses and Patients Should Question. Here it is in short form—full explanations of the rationale for each item are available at the above link.
- Don’t automatically initiate continuous electronic fetal heart rate
monitoring during labor for women without risk factors; consider intermittent auscultation first. - Don’t let older adults lay in bed or only get up to a chair during their hospital stay.
- Don’t use physical restraints with an older hospitalized patient.
- Don’t wake the patient for routine care unless the patient’s condition or care specifically requires it.
- Don’t place or maintain a urinary catheter in a patient unless there is a specific indication to do so.
The Choosing Wisely initiative encourages health care provider organizations to create their own lists of tests and procedures that may be overused, unsafe, or duplicated elsewhere. Using these lists, providers can initiate conversation with their patients to help them choose the most necessary and evidence-based care for their individual situations. The lists are not meant to be proscriptive, and also address situations where the procedures may be appropriate.
The Choosing Wisely campaign is in alignment with the recent focus on patient-centered care, identified as one of the factors necessary for high-quality health care in a 2001 report from the Institute of Medicine. It is also worth noting that the initiative is in accord with goals of the Affordable Care Act (ACA), which has focused attention on improving quality of care while also controlling costs by reducing the use of unnecessary and sometimes harmful procedures and tests.
The AAN joins nearly 100 other health care organizations, which have together identified more than 250 different tests, procedures, and practices that should be discussed with patients to help them make the best decisions for their care. All of the lists can be found here. No doubt the nursing-specific list could be a lot longer. Feel free to let us know your ideas.—Michael Fergenson, senior editorial coordinator, and Jacob Molyneux, senior editor
Jacob,
You wrote : “…and it appears that many of the same people who support such recommendations are also supporting initiatives to address those perennial issues.” This is not true. Hospital administration goals are different from nursing goals. Nurses want what’s best for the patient. The administration often cares more about the bottom line. This is not blaming them; this is merely their role. I have met a lot of wonderful, supportive hospital administrators yet their hands are tied when it comes to trying to get the support nurses need to do their job effectively in place.
You also mentioned you didn’t see any blaming going on here. I suspect this is because you are not familiar with the culture of nursing or hospitals. The rest of the items on this list, for example, may be nothing to do with nurses and simply hospital policy that if nurses do not abide by, their jobs may be in danger. For example, many nurses hate waking patients for minor care that can wait until the morning, but if they do not, they did not abide by the hospital standards and are at risk of being fired.
Again, I agree that involving the patients in their care is paramount to patient-centered care that all nurses strive to achieve. What leaves a sour taste in my mouth is the title “Five Things that Nurses and Patients Should Question,” like somehow nurses or patients have any control over it- perhaps that is also a phrase that hints at blame. Patients can not see this side of the equation, so they are left questioning why the nurse isn’t walking her elderly mother, why she is waking their family member in the middle of the night, etc.
NurseyNurse: Again, you raise strong points, but there’s an apples and oranges aspect to this exchange: when speaking of those who make such practice recommendations and who also support better nurse staffing, I am actually not speaking of hospital administrators but instead those who make policy and conduct research.
Your point that hospital administrators and policies may be at odds with what nurses know to be best practices and also at odds with such recommendations is perfectly valid. We hear about this constantly from nurses across the country. Such recommendations as those in the AAN’s Choosing Wisely list seem designed as much to target hospital administrators and health system leaders as to address nurses who may, in many cases, be able to do little to make them a reality without active hospital support in doing so.
So again: I’d suggest that the goal is not to create unrealistic lists that might be used to assign blame to individual nurses. I’m going to leave further responses or discussion on this topic to other readers, but, as noted, your experience and frustration appear to be widely shared, you make excellent points, and I for one would hope that those who make such lists can hear such input from nurses and do more to bridge the gap between ideals and experience. Thank you for weighing in.-Jacob
This is all fine and good, and of course an ideal way to practice. However, whoever wrote this clearly has never been in the position of working in an overcrowded, understaffed ED where you have no other choice then to restrain elderly patients (albeit safely, with regard to their special needs). It’s either that, or they risk falling from bed and breaking a hip. I have had my hand forced when I have no support staff, no care aids, no one to sit with elderly confused patients who continually try to climb out of bed- and the bedside rails merely provide an obstacle over which to climb and create an even worse fall, probably with a limb tangled in the railing. I hate doing it, and of course do it only when I have zero other options. But sometimes, zero options are all I have.
Same goes for not letting elderly patients lay in bed or get up to sit in a chair. Of course I’d love to take elderly patients around for a walk, but is that possible? With no support staff, and sometimes a need for a second person to assist with mobility/walking, these recommendations are a far cry from what can realistically be accomplished.
People who write these guidelines need to spend a day in the life and get a clue. Of course these are brainless, common-sense standards that they teach you in year 1 of nursing school. In the real world, it’s a different story. You do your best, hope your patients don’t crash on you as you juggle 10 things at once. And you should leave feeling like you did a great job in a tight spot, not guilty because you had to resort to restraints or because you didn’t get granny up for a walk.
You raise important points. Whether those who wrote these recommendations–and this is all they are, not guidelines–mean to blame nurses who are dealing with inadequate resources or instead point out goals that organizations should shoot for is another question. Along with such goals comes the need for better staffing, among other improvements…and it appears that many of the same people who support such recommendations are also supporting initiatives to address those perennial issues. Is progress being made? That’s not always so clear. Still, it’s hard to see any blaming going on here, but maybe a little idealism, given the realities “in the trenches” as you and many others describe them. Many of the Choosing Wisely lists are about engaging patients in more of the decisions about their own care, to the extent possible, so that’s another way to look at this as well.–Jacob M., senior editor
So, what is so “new” about this. Oh, wait, common sense went out the window years ago, right? So now you think you have to try to teach nurses common sense? Go figure.
However, it is the result of this litigious society and the administrators reactions that have created these nonsensical policies and procedures. Now thousands, probably millions of dollars can and will be spent studying this and re-inventing the wheel.
My clinical leaders, nurse supervisors, directors, CEO’s, etc., at the end of my career had spent essentially zero time in the trenches and were very (if not totally) focused on the “bottom line”. Policies and procedures were created to both enhance the bottom line and to avoid that ever threatening lawsuit.
The “powers that be” had/have vey little idea what actual bedside nursing entails. They were/are good, however, at creating policies and procedures that often make very little sense. If they had asked the nurses in the first place, time and money wouldn’t have to be spent now on re-inventing the wheel. Just saying.
Thank you for sharing. Hopefully these things will become standard practice.