Lisa Day

Evidence-Based Practice, Rule-Following, and Nursing Expertise

While it still has critics, the evidence-based practice movement has made great headway in medicine and nursing. Nurses are encouraged to use the best available evidence to guide their practice and to form the foundation for institutional policies and procedures. Evidence-based practice standards developed by professional organizations are implemented as sets of rules for nurses to follow as they care for populations of patients. For example, ventilated patients must have the heads of their beds raised to 30o and receive oral care at least every 4 hours in order to prevent pneumonia; patients with central venous catheters must be bathed daily with a chlorhexidine gluconate body wash in order to prevent line-related bloodstream infection. These kinds of evidencebased rules are put into place and then rates of ventilator–associated pneumonia, central venous catheter–associated blood stream infection, and nurses’ compliance with the rules are measured against institutional and national benchmarks. Standardized practice and habituated rulefollowing are vitally important to certain areas of nursing practice, and following procedures to the letter is sometimes the only way to ensure safe patient care. But as more nursing practice comes to fall under rules generated by research evidence and more emphasis is placed on strict adherence to procedure regardless of the situation, we risk losing touch with expertise. In this column, I will discuss the novice to expert model of skills acquisition as described by Dreyfus and Dreyfus and applied to nursing by Benner. I will argue that, as a form of rule-following, practice based on research evidence is limited in its ability to capture essential domains of nursing practice and that reducing the practice to sets of rules to be followed precludes expertise. There is a place for rule-following in expert practice but we must be careful not to let rules take over to the point that existing experts are deskilled and expertise is no longer fostered.

What Is Documentation For

N urses in hospitals across the United States feel burdened with the odious task of documentation. Many nurses think documentation takes too much time—time they would rather be spending with patients and families. Every nursing school teaches the importance of documentation and this is reinforced in all acute care settings. Yet the disconnection between documentation and essential nursing practices is disturbing, which leads me to ask, “What is documentation for?” As required documentation becomes increasingly standardized and focused on auditable performance measures, it moves further away from articulating those aspects of nursing that cannot be made auditable. Nurses find documentation to be an odious task because the documentation process does not ask them to articulate—and so routinely fails to capture— nurses’ concerns for the particular patient. In this column, I will explore the move toward standardized documentation and argue that making documentation auditable alienates it from the central concerns of nurses. When no other officially recognized means of articulating the practice exists, auditable documentation threatens to replace true practice with the documentation of practice. This will rob nurses of the essential skill of articulation.

Medical Futility, Personal Goods, and Social Responsibility

H ow to recognize when medical treatments are futile and how to respond as a conscientious and ethical physician has been discussed in the medical literature and in medical practice for many years. The problems that ensue when a patient or family demands what are considered by providers to be unreasonable treatments seem to come up more often as more technologies become available to sustain life and prolong dying. Despite the risk of redundancy (there is already a flood of literature addressing medical futility), in this column I will review some aspects of the medical futility debate and suggest that discussions of treatment futility ought to consider the benefits and burdens to the larger community and include public debate of the social responsibilities of providers and patients.