Evidence-based Practice: Only the Beginning

January 16, 2009

When I look at how things have changed and how they continue to change, especially in oncology nursing, I realize how far we have come.

I have been a nurse for seventeen years. For some that seems like just a beginning and for others a lifetime. I suppose it is all in the way you look at it. I can see it from a couple different perspectives. For me personally, it seems like I am just beginning and just coming into what I really want to be accomplishing as a nurse. But when I look at how things have changed and how they continue to change, especially in oncology nursing, I realize how far we have come. It does seem like a lifetime ago when nurses did things the way we did when I began my career. There are so many things that I can look back on now and wonder what in the world we were thinking. For instance, do you remember what the standard treatment for pressure ulcers, (of course then we called them bedsores) was, especially those that occurred on the sacrum of frail, elderly patients? We would turn them onto their side, tape their buttocks apart by attaching one end of the tape to them and one end to the bedrail, and direct a heat lamp at the sore to dry it out. Now, of course, we know that a moist wound better promotes better healing and that simple relief from pressure points can help to prevent ulcers from forming. What about preparing chemotherapy? Do you remember standing at the sink in the medication room and mixing your own chemotherapy? There was no hood or special ventilation. If we practiced “safely” we would double glove, but that was it. There was no such thing as verifying chemotherapy with another RN. We took an eight-hour overview course that covered the basics and then it was assumed that we were proficient. We have come so far with our safe practices and environments of care.

The options for how we treat our patients have also improved dramatically. For instance, before the dawn of ondansetron or granistron, when a patient was being admitted for a chemotherapy regimen that included platinum-based chemotherapies we had a specific procedure. The bed would be covered in chux pads, a lock belt would be placed on the bed, and several washbasins would adorn the room. We did not have HT3 receptor antagonist drugs available at that time so we used what worked best, lorazepam. The patients still got violently ill, throwing up almost incessantly, but they wouldn’t remember it at all. How things have changed and how wonderful for both our patients and the nurses. It wasn’t easy to put your patient through that. Now, armed with such things as better pharmaceuticals, a greater understanding of how different classes of antiemetics effect areas of the brain, high level research, and nursing autonomy, we can determine which antiemetic will work the best for our patients based on evidence rather than limited choice.

There are examples that are certainly more recent also. Within the last 3-4 years it was standard practice at my institution to use salt and soda mouth rinse as well as chlorhexadine rinse for oral mucositis. It was not until the literature was reviewed and recommendations for nursing interventions were published by the Oncology Nursing Society (ONS) via their Putting Evidence Into Practice (PEP) project that we found out not only was chlorhexadine not effective it was harmful. Practice changed. When the question arose from staff nurses as to why our patients could not have fresh fruit or vegetables when they were neutropenic, the literature was reviewed. Practice changed based on both a review of the literature and recommendations from ONS PEP cards. The use of an early warning system to objectively identify patients at a high risk for impending code situations was put into place based on research and review of the literature. With implementation of the Modified Early Warning Score (MEWS), we have reduced our preventable codes to zero in my department (Stenhouse, C, Coated, S, Tivey, M, Allsop, P, Parker, T, British Journal of Anaesthesia 84: 663P, 1999).

So, yes, a lifetime ago things were different. But equally as true, we are just beginning. The use of evidence-based practices empowers nurses to become beacons of excellence. For me, I look forward to what lies ahead.