162 Chapter 6 Background Healthcare professionals intentionally or unintentionally order tests, treatments and perform procedures on a daily basis that offer little or no benefit to patient care. This low-value care is proven to be ineffective or has not been proven to be effective, can even harm patients and waste valuable resources [1-3]. In addition, it wastes time that the healthcare professional can spend on more effective practices or care that is left undone [4, 5]. The Institute of Medicine estimates up to 30% of care provided in the United States is wasted on low-value care [6]. If even a fraction of this low-value care could be eliminated, the resulting quality improvement and cost savings would be transformational [7]. Most initiatives to eliminate low-value care are mainly focused on care provided by doctors [8], but many low-value procedures are also routinely performed by nurses [4, 9]. Well-known examples of low-value nursing procedures include the use of physical restraints in patients with a delirium, the use of bandages for wounds closed by primary intention, and performing a bladder washout [4]. Since nurses are the largest group of healthcare providers [4] there is a great potential in improving quality of care by involving and targeting them in de-implementation initiatives [4, 10]. As a first step to reduce low-value nursing procedures, ‘Choosing Wisely’ lists of nursing procedures are recently created in several countries [1, 4, 11, 12]. The next step is to translate these ‘Choosing Wisely’ lists into action [13]. To actually reduce the use of low-value nursing procedures, awareness should be created for the ‘Choosing Wisely’ lists and effective de-implementation strategies need to be developed and executed [7, 14, 15]. These de-implementation strategies should be theory- and evidence based and informed by analysis of barriers and facilitators that influence the use of low-value care, since this is expected to increase the adherence, adoption, and effectiveness of these deimplementation strategies [5, 16, 17]. A previous systematic review performed by Colla et al. [7] already reveals that multifaceted de-implementation strategies targeted at healthcare providers and patients have the greatest potential to reduce the use of low-value care. Besides, clinical decision support tools, performance feedback and education (alone or as part of a multifaceted strategy), are promising strategies for reducing low-value care. However, Colla et al. [7] also noted that little is known about interventions directed at non-physician staff members such as nurses, and that most interventions targeted at non-physician staff are aimed at assisting physician’s decision-making. So, it is still unknown whether the conclusions about effective de-implementation strategies also apply for the reduction of low-value nursing procedures. Since nurses might have other learning styles than physicians [18], other strategies could be more effective to de-implement low-value
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