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Unlearning outdated practices: using the evidence to deliver better patient care

Clark, Robyn A.

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JBI Database of Systematic Reviews and Implementation Reports: June 2019 - Volume 17 - Issue 6 - p 1016-1017
doi: 10.11124/JBISRIR-D-19-00189
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Recently, while attending the EuroHeartCare conference in Milan, Italy (May 2-4, 2019), I was very impressed by a poster from my colleagues van der Wal and Jaarsma.1 The poster presented a survey of 168 nurses in the Netherlands who cared for patients with heart failure (HF) and asked about the practice of fluid and sodium restriction.1 Although a widespread and well-established practice, there is little evidence for fluid and sodium restriction in patients with stable HF. Recent guidelines (2016) from the European Society of Cardiology recommend that patients with HF should avoid excessive fluid and salt intake, but that fluid restriction of 1500–2000 mL per day should be considered only in patients with severe HF to relieve symptoms and congestion.2

The purpose of van der Wal and Jaarsma's study was to determine to what extent these guidelines had been incorporated into current daily practice in HF. Most of the nurses in the study (69%) recommended standard fluid restriction ranging from 1500 to 2000 mL per day in patients with stable HF, while 12% of nurses advised their patients to drink a maximum of 1500 mL per day. In total, 42% of the nurses reported that the rationale behind their advice was based on recent guidelines. Regarding sodium restriction, 43% of nurses recommended that patients restrict their daily sodium intake to a maximum of 2400 mg, 13% of nurses reported advising patients to reduce their daily sodium intake to 2000 mg and 18% of nurses recommended that patients not add salt to their meal. Again, most nurses (63%) said their advice was based on HF guidelines, although the practice was not recommended by the guidelines or supported by evidence.1

Since reviewing this study, I have been wondering, when it comes to implementing the latest research, is it harder to unlearn a practice that is proven to have no evidence? I believe nurses struggle more with the implementation of guidelines when a change to an old, established practice is required. This premise was supported by the van der Wal and Jaarsma study.

There is universal acknowledgment that the clinical care provided by nurses should be informed by the best available evidence. Knowledge and evidence derived from robust scholarly methods should drive our clinical practice and decision making to improve the way we deliver care. Translating research evidence into clinical practice is essential to providing safe, transparent, effective and efficient health care that meets the expectations of patients, families and society. Despite its importance, however, translating research into clinical practice is challenging, particularly if an innovation requires complex changes to nursing education, clinical routines, collaboration among disciplines, changes in patients’ behaviors or changes in the organization of care.

Although the rate of new evidence production is increasing rapidly, change in clinical practice to reflect this evidence has lagged. For example, in a large nationwide cross-sectional study in Australia, clinician compliance with providing evidence-based care for 22 conditions ranged from 32 to 86%.3 In the United States, it was reported that less than 20% of what physicians do has solid research to support it.4

Since the evidence-based practice revolution, nurses have been required to unimplement many ancient rituals, such as rubbing backs, frequently dressing wounds, laying babies on their stomachs, using pethidine during labor and delivery, administering emergency oxygen to patients with chronic obstructive pulmonary disease and wiping skin with alcohol swabs before injections. Delivering high-quality, evidence-based care requires a lifelong commitment to learning. We cannot rest on years of experience, because change is now constant.

With more nurses in the front line of health care than any other health profession, nurse-led research is increasingly recognized as a critical pathway to reducing hospital errors, curbing unnecessary costs and improving patient outcomes. For an example of a nurse-led initiative to implement better practice based on current evidence, see this issue's best practice implementation project on preventing postoperative catheter-associated urinary tract infections.5

The clinical practice survey conducted by van der Wal and Jaarsma1 is just one of many instances of nursing researchers working with their clinical counterparts to alert health professionals to new evidence, or in some cases a lack of evidence, and a need for practice change.


1. van der Wal M, Jaarsma T. Fluid restriction and sodium restriction in daily practice at the HF clinic. Eur J Cardiovasc Nurs 2019; (In press).
2. Ponikowski P, Voors AA, Anker SD, Bueno H, Cleland JFG, Coats AJS, et al. 2016 ESC guidelines for the diagnosis and treatment of acute and chronic heart failure: the Task Force for the diagnosis and treatment of acute and chronic heart failure of the European Society of Cardiology (ESC). Developed with the special contribution of the Heart Failure Association (HFA) of the ESC. Eur Heart J 2016; 37 27:2129–2200.
3. Runciman WB, Hunt TD, Hannaford NA, Hibbert PD, Westbrook JI, Coiera EW, et al. CareTrack: assessing the appropriateness of health care delivery in Australia. Med J Aust 2012; 197 2:100–105.
4. Kumar S, Nash DB. Demand better! Revive our broken healthcare system. Bozeman, MT: Second River Healthcare Press; 2011.
5. Liang C-C, Huang T-J, Yang S-H, Su J-Y, Mu P-F, Curia M. Prevention of catheter-associated urinary tract infection in neurological post-operation patients: a best practice implementation project. JBI Database System Rev Implement Rep 2019; 17 6:1256–1267.