Health care's focus today is on value—to improve patient outcomes and safety while controlling or lowering costs. There are many ways to address value, but one direct path is to reduce the use of unnecessary or harmful tests or procedures that are not evidence based. Such interventions are considered “low-value care” and can contribute to high health care costs. The use of low-value care may be perpetuated by a number of factors, including gaps in providers’ knowledge, clinical habits, reimbursement structures, malpractice liability concerns, or patients’ expectations.1
In response to the crisis of rising health care costs and the overuse of wasteful, low-value care, the American Board of Internal Medicine (ABIM) Foundation and Consumer Reports launched the Choosing Wisely campaign in 2012.2 The purpose of this campaign is to motivate health care professionals and specialty societies to identify treatments and tests within their domain that are unnecessary or potentially harmful. The overall goal of the campaign is to achieve greater awareness of the campaign and help clinicians start conversations with patients about care that is supported by evidence so they will make smart and effective care choices.3
A role for nurses. In 2014, ABIM expanded the Choosing Wisely campaign to include nonphysician providers who are members of the health care team, forming partnerships with the American Academy of Nursing (AAN), the American Dental Association, and the American Physical Therapy Association. According to the Choosing Wisely campaign website, as of September, the campaign was active in more than 20 countries, with local support from numerous national clinician societies and associations. This number continues to increase.
Questionable nursing practices. In the fall of 2013, the AAN hosted nurse leaders from differing subspecialties to review a list of unnecessary or potentially harmful nursing practices that occur in the clinical setting. This was followed by further work to narrow down the list to 25. In October 2014, the AAN released an initial list of five evidence-based recommendations4; since then, 20 more recommendations have been published, bringing the current list to 25. (For the full list, see Table 1.) The recommendations cover a wide range of nursing practices, from bedside to advanced practice, and a spectrum of patients, from neonates to the elderly.
Educating nurses on the Choosing Wisely campaign. Although nursing's involvement with Choosing Wisely began over four years ago and affects a wide range of settings, knowledge of these recommendations may not be widespread throughout nursing. Although little appears to have been published regarding changes in practice related to the Choosing Wisely campaign, one 2015 Texas survey sought to assess nurses’ knowledge and perspectives on the campaign.6 A convenience sample included participants from the Texas Nurses Association, the Texas Organization of Nurse Executives, and the Texas Team Advancing Health through Nursing. A total of 374 nurses participated. Two hundred ninety-five RNs were asked about the Choosing Wisely for nursing campaign and 79 advanced practice registered nurses (APRNs) were asked about recommendations from the initial Choosing Wisely campaign for medicine. Only 21% of the RNs and 26% of the APRNs had heard of the campaign. Among physicians, at least one study found a similar lack of knowledge about the campaign.7
Practice changes related to the 25 Choosing Wisely recommendations for nursing have been largely institution or unit focused and inconsistent across health care settings. In my experience about pulmonary care, there continues to be clinical inertia in changing some of our practices, in particular recommendation 10, advising against the use of supplemental oxygen in cancer patients with dyspnea who don't have hypoxia, and 21, advising against the routine use of graduated compression stockings to prevent postoperative venous thromboembolism. Why the inertia? It is not because nurses want to provide care that is not evidence based. But nurses need assistance from educators, clinical nurse specialists, journals, and professional organizations—to name a few important resources—in order to keep up with our changing practice. We also need to discuss these Choosing Wisely recommendations in an interprofessional environment that promotes evidence-based practice as a team effort.
How can nurses support the campaign? Nurses will continue to need education on this campaign as more recommendations are released over time. How can nursing use these recommendations and help in their dissemination to nurses and patients?
- Evaluate your own practice and determine how often you have provided care using any of these recommendations.
- Discuss recommendations appropriate for your unit or practice setting at a staff meeting and follow up by discussing the available evidence on the specific treatment or intervention. On the Choosing Wisely website, each of the 25 questionable nursing practices listed is accompanied by a summary of supporting evidence for the recommendation, as well as information about potential alternatives for care (see www.choosingwisely.org/societies/american-academy-of-nursing).
- Disseminate these recommendations through nursing education at hospitals, ambulatory care centers, and schools of nursing. When appropriate, include these recommendations in orientation and ongoing education.
- Evaluate your electronic health record system and determine if any of these recommendations are part of current nursing care documentation.
- Engage in conversations with patients and families to help them better understand evidence-based practice. Informed patients and families are more likely to question care and make informed decisions.
- Utilize the materials for patients provided by the Choosing Wisely campaign, such as “5 Questions to Ask Your Doctor Before You Get Any Test, Treatment or Procedure” (available at www.choosingwisely.org/getting-started/resource-library/additional-materials-for-patients).
- Review the Choosing Wisely website for medical recommendations that may be appropriate for your practice setting; see www.choosingwisely.org/clinician-lists. Engage in conversations with your physician providers to discuss recommendations and how to improve care and support evidence-based practices.
The nursing recommendations are a starting point to further our use of evidence-based practice. Practice that is not supported by evidence wastes providers’ time, squanders our health care resources, and may place patients at risk. If health care is to improve the value of care provided to our patients, the interprofessional health care team needs to collaborate and implement the Choosing Wisely recommendations across all disciplines.
1. Zikmund-Fisher BJ, et al Perceived barriers to implementing individual Choosing Wisely recommendations in two national surveys of primary care providers J Gen Intern Med 2017 32 2 210–7
2. Wolfson D, et al Engaging physicians and consumers in conversations about treatment overuse and waste: a short history of the Choosing Wisely campaign Acad Med 2014 89 7 990–5
4. [no authors.] American Academy of Nursing announced engagement in national Choosing Wisely campaign Nurs Outlook 2015 63 1 96–8
6. Bradshaw P What do nurses know about Choosing Wisely? Texas Board of Nursing Bulletin 2016 47 3 6
7. Colla CH, Mainor AJ Choosing Wisely campaign: valuable for providers who knew about it, but awareness remained constant, 2014-17 Health Aff (Millwood) 2017 36 11 2005–11