Molly Jones is a 76-year-old woman who is scheduled for gallbladder surgery. Her surgery, scheduled for 8 a.m., has been pushed back to noon. When you conduct your preoperative assessment, you learn Molly hasn’t had anything to eat or drink since midnight. She is uncomfortable and complains of dizziness. You start to wonder if the instruction not to “eat or drink anything after midnight” has helped — or hurt — Molly risk of complications.
Those outside the perioperative environment often think of it as a mysterious place full of strange equipment. But for those who choose perioperative nursing as their specialty, it’s an exciting, rewarding setting where they can apply the nursing process to improve patient outcomes.
As with other specialties, gone are the days that perioperative nurses do things because, “This is the way we have always done it.” They use evidence-based practices to provide the best care possible to keep patients like Molly Jones safe. Evidence-based practice can be defined as “a problem-solving approach to practice involving a conscientious use of current best evidence in making decisions about patient care.” 1 By using this approach, information can be integrated into care delivery and disseminated to the bedside clinician.1 Evidence-based practice guides the decisions nursing professionals make and ultimately improves the care delivered to our patients.
Putting Evidence Into Practice Against Sacred Cows
“Sacred cows” are practices that are followed, but don’t have any evidence to back them up. One definition for a sacred cow is “stubborn loyalty to a long standing institution which impedes natural progress.”2 Another source states, “Sacred cows can impede the introduction of best practice in the patient care environment because they are often practices based on tradition, not science.” 3
Past perioperative sacred cows include perioperative staff members walking into the operating room suite and then stepping in disinfectant solutions poured on a drape on the floor to decrease the risk of infections at the surgical site,4 removing hair from the surgical site with a razor prior to skin preparation, and believing that gowning and gloving oneself from the back table was acceptable.
But sacred cows are still among us, according to a survey of 50 U.S. hospitals that reported all participants believed sacred cows existed in their facility.5 (Level B)
These outdated practices included timed surgical hand scrubs, the use of cover gowns over scrubs outside the perioperative setting, and wearing shoe covers. They are just a few examples of current practices in some perioperative settings that do not have a scientific basis on which to base one’s nursing practice.
Sacred cows become part of common practice simply because they have been performed for so long without being questioned. So, the first step in getting rid of a sacred cow is to identify it. When a practice or action is commonplace in the perioperative setting, the perioperative nurse should ask two questions: “Why are we carrying out this practice?” and “Is there current research to support this action?” If a nurse can’t answer these basic questions, it’s time to formulate a question to guide an investigation to determine if evidence supports the practice in question. For example, a nurse might ask, “Does performing a timed surgical scrub reduce the risk of surgical infections?”
To help answer questions, we can turn to research studies and other resources, such as standards. Standards are not intended to prescribe practice; rather, they provide a framework. Like all nurses, perioperative nurses follow standards of practice from the American Nurses Association. They also look to organizations, such as the Association of periOperative Registered Nurses, which focus specifically on perioperative care.
AORN is a national association recognized as an authority on safe perioperative practices. Its mission is to advocate for excellence in perioperative nursing practice and healthcare. AORN’s annual set of Perioperative Standards and Recommended Practices are based on available evidence that helps determine the best means to optimal decision making regarding perioperative patient care.6 These standards also serve as the foundation for the recommended practices, competency statements, guidelines, and guidance statements found in the same publication.
How can we evaluate the research behind AORN standards and other guidelines without seeking out each study ourselves? AORN made it easier in June 2010 when it began rating evidence.
Using a rating method adopted from the Oncology Nursing Society, AORN’s recommended practices are now labeled Recommended for Practice, Likely To be Effective, Benefits Balanced With Harm, Effectiveness Not Established, Effectiveness Unlikely, and Not Recommended for Practice. The ratings are applied to all AORN clinical practice recommendations in the perioperative setting.7 These ratings define for the perioperative nursing staff the strength and credibility of the evidence gathered, allowing nurses to make the best possible care decisions for their patients.
Of course, nurses can’t rely solely on standards, which are only periodically updated. It’s also important to conduct a literature search to identify relevant research articles. The ONS method is just one of several used to evaluate research. For example, the Gannett Education has established guidelines for its continuing education articles. The key is to select a method that is well respected and fits well with your practice setting. Keeping the same method helps ensure consistency from one project to another.
Levels of Evidence
No matter what method of analysis you use, evidence ranges from the strongest (Level A in the case of Gannett’s system) to the weakest. Here are examples of each:
Level A: Evidence from randomized controlled trials, meta-analysis, clinical practice guidelines
Level B: Evidence from well-designed controlled trials without randomization, clinical cohort studies, case-controlled studies, epidemiological studies
Level C: Evidence from consensus viewpoint and expert opinion, metasynthesis
Fortunately, we don’t have to reinvent the wheel. Several resources provide useful summaries of evidence, including Cochrane Reviews from The Cochrane Collaboration and the National Guideline Clearinghouse from the Agency for Healthcare Research and Quality.
The evidence will point nurses in the right direction when deciding if a sacred cow practice needs to be stopped, and it also provides guidance as to what practices should be in place. It’s important to evaluate practice changes to determine if they are effective.
Next, we’ll look at areas with sacred cows: nothing by mouth (NPO) after midnight, the surgical scrub, and double gowning.