ANNA MARIE, a graduate nurse in her second week of hospital orientation, responds to a patient's call light. The patient tells her he feels lightheaded and dizzy. She assesses his vital signs that include a heart rate of 118 beats/minute and BP, 72/48. Her preceptor, Kathy, a nurse with 30 years' experience, enters the room. When she learns the patient's BP, Kathy immediately puts the patient in Trendelenburg position.
When Anna Marie asks why she's done this, Kathy says, "It will help bring his BP up." When Anna Marie asks Kathy for a rationale, Kathy says, "I'm not sure; my preceptor taught me this intervention. I've always done it this way." Anna Marie didn't learn about that practice in school; she's dissatisfied with Kathy's response, which doesn't seem to be based on evidence, but she waits to see how the patient will respond. After all, Kathy has been a nurse for a long time.
Kathy's action, based on information that hasn't been scientifically validated, is known as a sacred cow. Sacred cows are outdated nursing practices that are ineffective, unnecessary, and sometimes dangerous.1 In this case, research has shown that Trendelenburg position increases venous return but results in little or no improvement in cardiac output or BP and can increase the patient's risk for hemodynamic compromise, increased intracranial pressure, and altered respiratory mechanics.1
Nursing journal's survey report, "20 Questions: Evidence-based Practice or Sacred Cow?" published in March 2014, provided an opportunity for the nursing research and evidence-based practice (EBP) council at University of Pittsburgh Medical Center (UPMC) St. Margaret to investigate ingrained nursing practices and assess staff education needs. The purpose of this project was to compare the national results of the Nursing journal's sacred cows survey to responses from nurses at UPMC St. Margaret's 229-bed community hospital to identify areas of EBP deficit and improve the hospital's quality of care.1
Seeking best practice
At UPMC St. Margaret's Magnet(TM)-recognized facility, the nurses are expected know the importance of exploring, supporting, and providing best evidence for practice. The hospital's strategic plan emphasizes an environment of inquiry in which all nurses apply EBP to improve healthcare delivery and patient outcomes.2
After approval was received from UPMC St. Margaret's quality improvement review committee, Nursing's survey instrument was sent to 631 nurses. Twenty-six percent (N = 164) responded over a 2-month period. All survey results collected were forwarded to the journal as part of its national results. Demographic information compares the UPMC St. Margaret respondents with the national respondents.
See Survey results for a comparison of national and UPMC responses to the 20-item survey instrument. Much like the national survey respondents, the UPMC St. Margaret respondents did better answering questions related to more prominent nursing practices, which are highlighted not only in the literature, but as health system directives. The areas where UPMC St. Margaret nurses' correct responses were less than 50% were the areas the EBP council chose to look at more closely.
A closer look
The correct response rate was less than 50% for 9 of the 20 survey items. Some of these results highlighted a particular need for more education and/or policy changes, but other results were worth celebrating. For example, the results for statement 2, "Scrubbing the hub of an I.V. port for a minimum of 15 seconds before accessing a central line has been shown to reduce central-line associated blood stream infections," showed that the "Scrub the Hub" campaign at the UPMC health system was very successful. Compared with 81% who answered correctly nationally, 96% of UPMC St. Margaret respondents answered that question correctly. Ongoing catheter-associated urinary tract infection prevention efforts at UPMC may have factored into question 19's 87% correct response rate and question 20's 88% correct response rate.
One outstanding deficit in both the national results and the facility survey was related to enteral feeding tubes (questions 5, 7, and 8). We found that our policy was outdated. It's now being revised to reflect EBP. UPMC St. Margaret also revised its policy of keeping healthy patients N.P.O. after midnight before the day of surgery and has initiated the Enhanced Recovery After Surgery program for orthopedic patients and is expanding it to other surgical patients.
As with the national survey, our project had several limitations. Not all of the respondents work in areas where they encounter some specific care issues. Age, years of practice, education level, and specialty certification may be factors as well. Some respondents may have guessed the correct answers, and a few respondents left questions blank or wrote, "I don't know."
This project has been presented at a nursing grand rounds to provide further education to the nursing workforce on a number of topics. The staff was enthusiastic and curious about the survey results and the rationales for correct answers, fostering much-needed discussion.
The concept of sacred cows has been incorporated into our graduate nurse residency program to facilitate dialogue about the importance of EBP. We believe that not only can novice nurses learn from seasoned nurses but the reverse is true as well.
Education
One of UPMC St. Margaret's current campaigns is to encourage nurses to attain their bachelor of science in nursing or an advanced degree, specialty certification, and membership in professional organizations. UPMC recognizes that certified nurses provide safer care; nurses with BSN degrees have enhanced critical thinking skills; and involvement with professional organizations promotes opportunities for continuing education.3-5 This falls in line with the Magnet mission. Will these efforts help eliminate sacred cows? We believe they will.
Facility-wide education about specific practices continues. More sacred cows than the 20 presented in the national survey still need to be addressed, such as aspiration when giving I.M. influenza vaccination injections, and nurses' uncertainty about the oxygen requirements of COPD patients. In addition to learning new things, we can't forget that what we've learned in the past may need to be updated along the way.
Practice makes perfect
So how did Anna Marie's patient fare? Anna Marie noticed that placing the patient in Trendelenburg position resulted in a temporary improvement in BP that quickly dissipated, and the patient had more difficulty breathing in that position. Anna Marie consulted with the patient's primary care provider, and the patient stabilized after being placed in supine position with the head of the bed horizontal relative to the patient's trunk and lower extremities elevated. The patient also received I.V. fluids and supplemental oxygen, and Anna Marie continued to monitor him closely. Later that evening, she researched the topic and found several studies that recommended against the use of the Trendelenburg position to treat hypotension or shock. She shared her findings with Kathy, who thanked her and said, "I had no idea. Maybe it's time for me to update my practice."
REFERENCES