Where is our nursing ‘Choose Wisely’?

Enrique Castro-Sánchez (@castrocloud) Associate Editor at Evidence-Based Nursing, Research Fellow at NIHR Health Protection Research Unit at Healthcare Associated Infection and Antimicrobial Resistance at Imperial College London, Honorary Nurse Consultant in Communication and Patient Engagement, Imperial College Healthcare NHS Trust, London.

Joining EBN journal is proving to be a fantastic personal experience and a great opportunity to help disseminate evidence-based nursing. In my opinion, the notion of avoidable care is intimately linked to such model of practice. The tests and procedures that we should not be doing to our patients does not simply refer to what may be harmful to them, but also to interventions that offer little or no added value to their care.

Engaging in low value care however has got obvious impact, in terms of the potential for iatrogenic events and opportunity costs. Whatever we decide to spend our time, energy and effort on cannot be spent somewhere else. And by the growing body of evidence related to ‘care left undone’ [doi: 10.1111/jan.12976], we already know that our nursing capacity and resources are insufficient.

Interestingly, the need to avoid unnecessary healthcare activities has been recognised around the world. The ‘Choosing Wisely’ initiative (www.choosingwisely.org) was developed in the US and Canada in 2012 with the purpose of encouraging doctors to discontinue interventions that were not evidence-based, harmless and necessary. As a nurse interested in communication and patient engagement, I also celebrate the focus on encouraging patients to make effective decisions about their care. ‘Choosing Wisely’ asked scientific societies and organisations to identify commonly used procedures and treatments that were deemed to be wasteful. The initiative has attracted attention in other countries, including Switzerland, Australia and Netherlands, among others. ‘Choosing wisely’ recently landed in the UK (http://www.bmj.com/content/350/bmj.h2308), although some policies such as ‘Simply Prudent Healthcare’ in Wales (http://www.prudenthealthcare.org.uk/), developed in response to cost and quality challenges, also pointed in the same direction.

And what about nurses?

The crucial role of nursing leaders in reducing unnecessary healthcare has been acknowledged (https://stti.confex.com/stti/bc43/webprogram/Paper76890.html), and some national organisations have already produced their top lists of avoidable interventions. For example, the American Academy of Nursing has actively collaborated with ‘Choosing Wisely’ and released a list of 15 needles procedures (http://www.choosingwisely.org/wp-content/uploads/2015/02/AANursing-Choosing-Wisely-List.pdf). Whether these procedures are nursing specific is perhaps not that clear, although such perception may simply respond to local organisational arrangements and nursing characteristics in the US. On the other hand, some of the considerations seem extremely pertinent to nurses worldwide. For example, the request not to wake patients up for routine care unless specifically required for the patient’s condition or care, or refraining from placing and maintaining a urinary catheter in a patient unless there is a specific indication to do so. A focus on safety-related interventions appears in the recommendations from the Australian College of Nursing (http://www.choosingwisely.org.au/recommendations/acn), including not replacing peripheral intravenous catheters unless clinically indicated.

In the UK, however, we have yet to produce similar agreements on what nursing care tasks or interventions we should not be doing. Of course, such absence should not be suggested to imply that nurses here do not enthusiastically share the rationale and spirit of the Choosing Wisely campaign. And perhaps before formal evaluations are conducted, we all should be reflecting upon the daily nursing rituals and traditions that we engage with and that are unlikely to make a difference in the life of our patients.

Finally, is it time for a ‘Choosing Wisely’ approach to our nursing (and wider) policy making and service delivery reorganisation?

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