President's Note: Why Do We Do the Things We Do? Stop the Carnage of Nursing Research
By Anne W. Wojner, RN, MSN, CCRN
President, American Association of Critical-Care Nurses
When I entered critical care nursing as a new graduate more than 22 years ago, we did some pretty strange things in the name of what we truly believed was good patient care. We didn’t always rely on science to direct our actions. Instead, we often operated from gut instinct, doing things that we honestly thought were in the best interests of our patients and families. Needless to say, we’ve come a long way!
As I think back, it’s easy to come up with a list of suboptimal, nonresearch-based practices that have been followed in critical care units throughout the United States.
Following are examples of the misguided rules that governed our practice before we knew better:
• Always stay in control of visiting hours, limiting visits to approximately 15 minutes, two to three times per day to decrease patient stress and force the family to rest.
• All patients with artificial airways must be suctioned routinely every two hours, or more often if necessary.
• Apply antacid to pressure ulcers every four hours to dry the wound and enhance healing.
• Always place patients who have suffered an acute myocardial infarction on prophylactic lidocaine drips for 48 to 72 hours.
• Always soak burn wounds in iced saline solution.
• Always position neuro patients, regardless of specific neurological diagnosis, with the head of the bed elevated 15 to 30 degrees.
• Always remember to strip your patients’ chest tubes at least every hour, to prevent them from becoming obstructed.
• Instill saline every time a patient is suctioned to loosen up secretions.
• For intubated patients, always measure end-expiration at the lowest point on the waveform.
• Lead II is always the best lead to use for cardiac monitoring.
• Always withhold nutrition for several days following a major injury, illness or surgery, because patients can live off their own body fat.
• Always use iced injectate solutions when shooting a cardiac output.
• Always shave your patients’ operative site prior to sending them to surgery, to lessen the risk of operative contamination or wound infection.
Interestingly, all these practices have one significant thing in common: They are all based in tradition and sometimes folklore, and do not represent research-based
practice. What is really scary about these types of legendary practices is that many nurses and other healthcare providers continue to follow them—sometimes daily! Why?
When I recently spoke about critical care nursing research at a conference in Hong Kong, the problem of research utilization in U.S. nursing practice was raised. Of note, was the shocked response by the critical care nurses in my audience. One nurse boldly took the microphone to ask,
"Why don’t U.S. nurses use their own research? Here in Hong Kong, we follow everything you do in the U.S., and when there is sufficient evidence that a practice should be changed or abandoned, we are quick to take up the suggestion. I don’t understand why those who are generating this evidence do not value what they have learned."I had to confess that I, too, do not understand this phenomenon.
As editors of the American Journal of Critical Care, Kathleen Dracup, RN, DNSc, and Christopher Bryan-Brown, MD, have repeatedly addressed our obsession with traditions, mythical practices and folklore in their fine editorials. They have pointed out a number of issues that drive the research utilization problem in the U.S. They have suggested that a major reason nurses do not base their practice in science may be a lack of understanding of the research process and the evidence produced.
This argument is certainly reasonable, and may be rooted in the individual’s nursing education program, degree of personal and professional initiative to improve understanding of the research process, the work setting and degree of exposure or involvement in research, and the support systems that facilitate research utilization within our organizations. Few of us enjoy cuddling up in front of a roaring fire with a research journal. Without a solid understanding of the process, and appropriate support systems to guide evidence-based changes in practice, many of us simply cannot keep up with the latest recommendations.
Dracup and Bryan-Brown have also identified cultural issues as barriers to research utilization. The culture of our unit or institution is often reflected in the way we respond when asked about a tradition-based practice.
"We always do it this way”; "We’ve tried that before and it didn’t work”; and
"This is the way we do things at our hospital; don’t buck the system"are among everyone’s personal favorites. Often the organization’s culture stifles nurses in questioning their practice—from wondering if there is a better way and wanting to know more about a phenomenon of interest. How sad!
Another reason Dracup and Bryan-Bryan have cited for the research utilization problem is the relatively small sample sizes used in many nursing and medical studies. Sample size limits the generality of findings—our ability to suggest that what a study measured may also occur in a vast majority of patients. The research examining optimal positioning for neuroscience patients is representative of this problem. Most of the published research in this area includes small samples of highly heterogeneous patients. Can we really conclude that the most effective treatment for a patient with traumatic brain injury is also the best for a patient with an ischemic stroke? Of course not. As a result, we are left with an answered question about our practice.
The fact that critical care is a relatively young specialty is yet another factor that Dracup and Bryan-Brown cite for the problem. Most of what we do as critical care nurses is not supported by evidence. Although we are slowly accumulating findings that support use of specific processes, many questions have not been adequately studied, or, for that matter, are still waiting to be asked.
It’s time to examine ourselves and our practice cultures, and actively strive to resolve this lack of research utilization. Because we live in a highly litigious society, we are placing ourselves and our organizations at significant risk when we don’t use evidence to support how we provide care. Of course, research utilization is right for patients and families. Why wouldn’t we want to provide the best possible care for those who trust us with their lives and the lives of their loved ones?
The next time you suction a patient, I’d ask that you not use saline. The next time you place a patient on a cardiac monitor, let the research guide your lead selection. Own up to those things you need to learn, and strive to improve your nursing care practices. Our patients and families deserve that, and nothing less!
My Turn: Critical Thinking Is Usually Not Rapid-Fire
By Rosalinda Alfaro-LeFevre
As a consultant who helps nurses acquire critical-thinking skills, I often meet people who mistakenly equate critical thinking with rapid-fire thinking, creativity and intuition. They want to know how to diagnose and treat patients quicker and easier. They seek quick fixes and easy outs, which is not critical thinking.
When you see expert clinicians in action, critical thinking may seem like "rapid-fire thinking."However, critical thinking is usually not rapid-fire. In fact, experts use rapid-fire thinking only under extreme circumstances. They know that the end result is often
"shooting from the hip.”
To improve performance, we must understand that acquiring critical-thinking skills—such as accuracy, reliability, recognizing inconsistencies and identifying patterns and missing information—takes time. Taking time to reflect as we practice is important. We must constantly evaluate and correct our thinking, asking questions such as,
"What am I missing?""Do I know what I need to know?""What else could be going on here?"and
"How can I do this better?"
Too many nurses are already at risk for "shooting from the hip,"because of work overloads and pressure from insurance companies to move patients through the system. However, critical thinking requires knowledge, skills, practice, caution and judgment. It often takes place best when away from the patient, in a quiet place with few distractions, or in a group, where there is input from various perspectives. We must value the need for time to think.
Creativity and right-brain thinking do not necessarily involve critical thinking, though an essential part of critical thinking is considering many ideas, alternatives and creative solutions. To think critically we must answer questions, such as,
"Have I fallen in love with my ideas?""Am I reinventing the wheel?"and "Which peers should I check with to address practical concerns?"Too often, creativity and brainstorming seminars deal with the creative process, but fail to address the judgment necessary to decide how to use creativity in the clinical setting in a safe, sensible way. Applying creativity requires both producing ideas (right-brain function) and evaluating and judging the worth of those ideas (left-brain function).
Equating intuitive thinking with critical thinking is a problem. Much has been written about the power of intuition in the diagnostic process and of the
"immediate knowing"of experts. However, little is said about how to use intuition or about how experts are able to
"immediately know,"except to say they know it intuitively.
As much as possible, critical thinking is based on evidence. When we teach nurses that critical thinking is intuitive thinking, we risk sending the message that it’s OK to act on gut feelings without much thought. Instead, we should teach the value of recognizing when we are experiencing
"gut feelings"and acting appropriately, as we do when we look for evidence to validate the
"gut feelings,"and closely monitor or plan for "what if"scenarios.
To think critically, you must be able to explain how you know what you know. If pressed, any nurse who says that he or she
"immediately knew something"will likely be able to provide a reasonable answer, such as
"I saw it happen before in a similar case"or "Things were different in subtle ways."The point is that nurses who
"know immediately"usually know because they are able to match the present situation with previous knowledge and experience—or, perhaps, they have taken the time to know the patient better than others have.
We don’t serve our profession by teaching nurses that some clinicians
"just know"because of the mystery of their intuition. These mysterious instances are the exception. By emphasizing that
"immediate knowing"is a result of previous experience and getting to know patients and their problems well, we teach the importance of gaining knowledge and experience, of making time to monitor closely and assess comprehensively, and of striving for continuity of care.
Without respect for the knowledge, experience, caution, judgment and time required to think critically, creativity and intuition are wasted. In addition, we are likely to see more
"casualties at the OK Corral,"because of "shooting from the hip."
Rosalinda Alfaro-LeFevre, RN, MSN, is president of Teaching Smart/Learning Easy, which provides consultation and seminars on critical thinking and the nursing process. She is also an author and teacher, who has more than 20 years in clinical practice, primarily in ICUs and emergency departments.