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Jean White: 'Beware the rituals – look for evidence behind your actions'


We must continue to invest in research and development work to improve care, says Jean White

In early February, I opened a new learning resource centre in the Carmarthen campus of Swansea University. This is an important development for a rural part of South West Wales, enabling students and clinicians access to a range of resources to inform their studies and practice.

The event made me realise how things have changed during my career as a nurse - particularly striking are the changes that enable us to find information. It feels like modern technology lets us have answers to every question at a press of a button - it just requires us to seek the answer. However, when I reflect on this simple premise, a number of questions spring to mind.

Are we investing enough energy in building the evidence base quickly enough? Is more collaboration the answer? Are we really learning from our daily practice and sharing this knowledge? How easy is it today to systematically translate new knowledge into practice? Are we risk averse when it comes to making changes? Where are our clinical academics? And how do we engage clinical staff?

‘Without evidence to guide our practice, we will resort to ritual and a “this is the way we do it here” mentality that may mean poor care’

I may not have a full answer to the above and other related questions but one thing I do know is that, without evidence to guide our practice, we will resort to ritual and a “this is the way we do it here” mentality that may mean poor care.

For anyone who is interested in historical nursing, Walsh and Ford’s book on nursing rituals is an amusing and horrifying read - horrifying as I remember being taught some of these practices as a student, for example putting egg white and oxygen on pressure ulcers and packing diabetic ulcers with Eusol. Every ward I went on had its way of dealing with certain problems that depended solely on the sister’s or consultant’s preference.

I hope this situation is a thing of the past but perhaps, every now and again, clinicians should pause and ask themselves why they are doing an activity and what evidence underpins it.

One of the things a small country like Wales does well is to work collaboratively to identify and share good practice that is underpinned by strong evidence of effectiveness. The 1,000 Lives Plus national programme drives improvements locally (, through mini collaborations and the use of care bundles. Nurses at one of our health boards have just celebrated seven wards being effectively pressure ulcer free for the last three years; this was a direct result of introducing the SKIN bundle - an evidence based set of behaviours.

Most recently, Wales has become the first country in the world to introduce a national early warning score (NEWS) to its whole healthcare system. NEWS was launched by the Royal College of Physicians’ working group in July 2012. Clinicians use NEWS to determine the level of risk of a patient’s physical condition deteriorating in a standardised way calculated from the routine patient observations, such as pulse rate. Although it is still early days, there is evidence of care becoming safer with earlier identification of acutely ill patients, effective recognition and treatment of sepsis and improved patient outcomes.

There are many examples like this throughout the UK, where clinical staff have reviewed then revised their practices so it complies with the best evidence. It is imperative that we continue to invest in research and development work, not as an academic exercise but with a clear purpose to improve patient care and outcomes.

I encourage everyone to ask questions, examine the evidence and act where appropriate and resist the easy temptation to fall back into ritual; it does our patients a serious disservice when we do.

Jean White is chief nursing officer for Wales


Readers' comments (3)

  • How can we avoid rituals when it is becoming a tick box profession on one hand. On the other hand, the wealth of research, as into safe staffing levels that save patient's lives, is chosen to be ignored. Not very encouraging!

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  • michael stone

    'Rituals' is interesting.

    I have recently been e-mailing various people, in connection with my issue, to the effect that I am not 100% keen on 'process above principle' (my area involves professionals and lay carers - laymen cannot be familiar with 'process', so how can reliance on 'process' work properly when both professionala nd lay carera are involved, and the patient is in his own home ?).

    Evidence that something 'works', is obviously a good idea - but often there isn't any evidence, and there is usually an assumption (not necessarily well-founded) that whatever is currently being practised, has got a decent evidence-base.

    And 'evidence' about things such as staffing levels is usually 'trickier' than evidence about clinical procedures (and it also attracts much more 'political interference', I think).

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  • I have always found that understanding why I do something makes more sense than simply doing it. I am surprised that others don't see things the same way.

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