CNA leads development of first nursing list for Choosing Wisely Canada

January / February 2017   Comments

Editor’s Note: The list, the rationale for the recommendations and the evidence used to develop them are now available online.


CNA is about to release Nine Things Nurses and Patients Should Question for the Choosing Wisely Canada campaign. This list of evidence-informed statements aims to reduce overuse of interventions that either have no clear benefit or could cause harm.

Choosing Wisely Canada was launched in 2014 to help clinicians and patients more easily discuss whether certain tests, treatments and procedures are necessary. To date, more than 50 national medical professional societies have engaged in the campaign, and 30 have already released more than 180 evidence-informed recommendations in total.

Highlighting nursing expertise, the CNA document will be the first non-medical list released as part of the campaign. “We are delighted to have nursing join the campaign, since tackling the problem of overuse needs the full health-care team in order to be effective,” says Dr. Wendy Levinson, chair and co-founder of Choosing Wisely Canada. “Nursing leadership is critical to many of these common overuse problems, and CNA is providing that leadership.”

Last April, CNA created a Choosing Wisely Canada nursing working group (NWG), made up of 12 CNA members from across Canada and across various specialties. NWG members were chosen from nominations submitted by selected groups of the Canadian Network of Nursing Specialties and by CNA’s jurisdictions. “The process enabled nurses across the country to have a voice to collectively advise about major care choices that have an impact on all Canadians, no matter where they live,” notes NWG member Marcia Carr from British Columbia. She is a clinical nurse specialist in medicine, geriatric medicine and geriatric psychiatry and a nurse continence advisor.

NWG members demonstrated a strong commitment, underscored by their belief that CNA should contribute its nursing voice and expertise to this project. “As a registered nurse, I expect our national professional association to provide up-to-date and relevant information that will influence my practice and the safety of my patients,” says Kathy Bouwmeester, a critical care nurse from Alberta and an NWG member.

CNA developed the list using a comprehensive validation method. First, the NWG reviewed existing recommendations, including items from Choosing Wisely Canada’s medical professional societies and the American Academy of Nursing’s Choosing Wisely list, which had already undergone rigorous evidence reviews. In addition, NWG members brought forward recommendations on new evidence-based items. They appraised 195 items for relevance to nursing, using a structured process developed for this work. The items went through several rounds of review before the group reached consensus on the final list of nine. A literature review was conducted to confirm the evidence for these items; supporting nursing research was added where appropriate. The list subsequently underwent extensive consultation with input from nursing experts in patient safety and various members of the Canadian Network of Nursing Specialties, as well as patient advocates, CNA’s jurisdictional members, CNA nursing staff and Choosing Wisely Canada’s internal clinician reviewers.

Deborah Viel, a supervisor of community public health nursing in Nunavut at the time she was an NWG member, says, “This group’s focus was to have a Choosing Wisely Canada list that represents a wide range of practice settings and a broad scope of nursing practice. That means there is still work to be done to develop lists that address overuse of interventions in specialty areas of practice.”

CNA is embarking on the next phase of this work, partnering with members of the Canadian Network of Nursing Specialties to develop two specialty lists later this year.


Nine Things Nurses and Patients Should Question

  1. Don’t insert an indwelling urinary catheter or leave it in place without daily assessment.
  2. Don’t advise routine self-monitoring of blood glucose between appointments for clients with type 2 diabetes who are not taking insulin or other medications that could increase risk for hypoglycemia.
  3. Don’t add extra layers of bedding (sheets, pads) beneath patients on therapeutic surfaces.
  4. Don’t use oxygen therapy to treat non-hypoxic dyspnea.
  5. Don’t routinely use incontinence containment products (including briefs or pads) for older adults.
  6. Don’t recommend tube feeding for clients with advanced dementia without ensuring a shared decision-making process that includes the known wishes of clients regarding future care needs and the perspectives of carers and the health-care team.
  7. Don’t recommend antipsychotic medicines as the first choice to treat symptoms of dementia.
  8. Don’t recommend antimicrobials to treat bacteriuria in older adults unless specific urinary tract symptoms are present.
  9. Don’t routinely recommend antidepressants as a first-line treatment for mild depressive symptoms in adults.
Karey Shuhendler, RN, CCHN(C), MN

Karey Shuhendler, RN, CCHN(C), MN, is a CNA policy advisor.

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