When More Is Not Always Better: Choosing Nursing Interventions Wisely
As healthcare professionals, Canada's nurses have the privilege and obligation to provide high-quality care. We pledge to do no harm to our patients, and we work together to make this happen. Yet, every day healthcare professionals order tests, treatments or procedures that offer little (if any) value to patient care. In fact, despite our commitment to our patients, such unnecessary care can do them harm – sometimes physically, sometimes psychologically – and also waste valuable resources for the health system.
The overuse of antibiotics is a good example of how unnecessary care can cause harm. Overprescribing these medications has led to the emergence of superbugs with antibiotic resistance, including the rise of Clostridium difficile in our hospitals, which can be deadly for the most vulnerable patients.
To curb this overuse epidemic, it is important that healthcare professionals work together to question their own practice habits and behaviours. We also need to engage in conversations with our patients about what they do and don't need. While we live in an age when "more is better," we must convey to patients that with healthcare interventions this is not always so.
To be most effective, it is essential that these conversations occur wherever care is being provided, whether on the exam table, at the bedside or in the home. Such discussions can help patients, their families and the public understand the potential value and harm of our interventions and encourage them to make smart and effective choices for high-quality care.
For these reasons, the Canadian Nurses Association (CNA) has joined the Choosing Wisely Canada (CWC) campaign by creating a list of nine things nurses and patients should question (https://www.choosingwiselycanada.org/recommendations/nursing/). In publishing its past lists, CWC has worked with over 30 national medical societies. The list from CNA, which represents 140,000 practising registered nurses across Canada, is the first to be developed by a non-physician national group. CNA is proud to be joining our physician colleagues in having conversations with ourselves and our patients about unnecessary care.
Conversations for Better Care
CWC has developed four questions to help start these conversations:
- Do I really need to provide this test, treatment or procedure?
- What are the downsides?
- Are there simpler, safer options?
- What happens if I do nothing?
Examples from the Nursing List
Below are three of the nine CNA recommendations, developed by its members, which show situations when more is not always better and ways for nurses to reduce harm for their patients.
Don't add extra layers of bedding (sheets, pads) beneath patients on therapeutic surfaces
As healthcare professionals, we want our patients to be comfortable. But evidence from our hospitals and long-term care facilities shows that additional bedding layers can limit the pressure-dispersing capacities of therapeutic surfaces (e.g., therapeutic mattresses or cushions). As a result, extra sheets and pads can contribute to skin breakdown and cause or delay the healing of pressure wounds.
Don't routinely use incontinence containment products for older adults
In a busy hospital ward or long-term care facility, it can be easier for patients to be in adult diapers or incontinence containment products than have them call for assistance to use the bathroom. But this all-too-common practice brings more harm than good. Patients' self-esteem and perceived quality of life is diminished from what can be an embarrassing and uncomfortable situation. In addition, using such products can lead to a higher incidence of skin problems and bladder infections.
Don't recommend antipsychotic medications as the first choice to treat symptoms of dementia
People with dementia frequently exhibit behaviors that are difficult to control, which can be perceived as violent or aggressive. Powerful antipsychotic medications are prescribed far too often for such patients and can cause serious harm.
About the Author
Barb Shellian, RN, President, Canadian Nurses Association, Ottawa, ON
Wendy Levinson, MD, Professor of Medicine, University of Toronto, Chair and Co-Founder, Choosing Wisely Canada, Toronto, ON
Correspondence may be directed to: Kevin Menard, Canadian Nurses Association; E-mail: firstname.lastname@example.org
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