ON LOW-VALUE NURSING CARE: PART 1, WHY DE-IMPLEMENTATION MATTERS FOR QUALITY CARE

SEVENTEEN YEARS to translate research into practice. This lag has long been cited as the amount of time before new science is adopted into practice.2 More recently, the lag has been downgraded—but only to 15 years.3 In addition to this research-to-practice gap, Garrow4 estimated that of 2500 treatments with good evidence, 15% were beneficial, 22% likely beneficial, 7% partially beneficial/harmful, 5% unlikely beneficial, 4% likely ineffective or harmful, with the remaining effectiveness unknown. These quality and safety outcomes underscore the importance of Choosing Wisely—campaigns launched in the United States,5 Canada,6 Denmark,7 and Australia.8 These campaigns highlight how some practices become entrenched in everyday routines; such practices are commonly referred to as “sacred cows,” “tradition-based,” or “low-value.”5–9 This problem is not unique to nursing. Overuse of health care services is recognized worldwide, from medications, screening and diagnostic tests, and therapeutic procedures to end-of-life care.10 Compared with how long it takes to adopt evidence-based practices, the amount of time that practices remain entrenched—further compromising quality of care and patient outcomes—is not known.De-implementation, first mentioned in the literature in 2008,11 is focused on reducing non–evidence-based practices steeped in tradition. Such practices provide no demonstrable benefit (or their associated harms outweigh their benefits) or are not cost-effective.12–14 More than “undoing,” de-implementation involves unlearning practices bounded by contextual factors.15 For example, Bourgault et al16 found that nurses were more likely to use a low-value practice like auscultating feeding tubes to verify placement if they observed colleagues performing it. Conversely, having a policy to stop a “do-not-do”, as Verkerk et al7 described, decreased the likelihood of such practices. Thus, the PICO (patient/population/problem, intervention, comparison, and outcome) question for this evidence synthesis was this: What nursing practices have been documented as low-value in high-acuity and critical care nursing?The strategy included searching CINAHL, OVID, PubMed, and AACN Practice Alerts. Key words were sacred cows, tradition-based, low-value care, de-implementation, nursing, and critical care. This search was focused on original research and synthesized evidence on low-value practices.Multiple articles described low-value practices across general or critical care settings (see Table).5,6,12,13,16–33 Practices were categorized as nursing assessment; hemodynamics; use and management of catheters, drains, and tubes; pulmonary management; blood and medication management; activities of daily living; and family involvement. Where appropriate, potential harms of low-value practices are noted. Goals for de-implementation of low-value practices vary, including As new evidence is generated on safety and clinical effectiveness, some practices become outdated and naturally need to be de-implemented. Thus, knowledge for practice continually evolves. Normalizing the life cycle of knowledge assists clinicians to understand the need to implement new evidence-based practices and to de-implement other low-value practices. One way to shape this culture of knowledge transformation is via systematic practice evaluation.37 Bourgault and Upvall9 found that critical care nurses were uncertain if practices were rooted in tradition or evidence and had a strong desire to understand practice rationales from multiple sources of knowing (ie, journals, professional organizations, well-informed colleagues). Strengthening a spirit of inquiry can shift the culture to where nurses consistently challenge the status quo—questioning routines, traditions, and sacred cows. Such clinical inquiry is essential for ongoing practice improvement.With the stage for practice evaluation set, nurses can critically appraise the evidence to become better informed about the state of the science (or lack thereof) for potentially low-value practices. Audits can be conducted to assess if organizational policies and guidelines contain such practices.37 These audits can be supplemented with surveys of clinical nurses and managers to determine level of nurse agreement, as well as perception of adherence and usefulness of recommendations against low-value practices.37,38 These data will help identify psychological processes or biases (see Figure) that make change difficult, and other barriers associated with each low-value practice.13,14,16,33,38,39 Survey data can be aggregated for an organizational perspective, and/or drilled down for a unit-level view of low-value practice usage. Policy audit and survey data can then be combined to “grade” each targeted low-value practice (see Hanrahan et al’s37 example of a standardized rubric). These practice evaluation steps (see Figure) lay the foundation for the de-implementation process.9,13,14,35,37–40 In Part 2 of this article, evidence about the effectiveness of de-implementation strategies in high-acuity and critical care nursing will be highlighted to assist nurses in removing, replacing, reducing, or restricting low-value practices in their units and organizations.