Choosing Wisely® Initiative: A Nursing Perspective
By Briana Witherspoon, DNP, ACNP, and Karen March, MN, RN, CCRN
In 2012, the American Board of Internal Medicine (ABIM)
Foundation partnered with Consumer Reports to create Choosing
Wisely®, an initiative focused on reducing the number of
unnecessary tests and procedures performed during a hospital
admission or clinic appointment. The overall goal of Choosing
Wisely® is to encourage dialogue between patients, families and
healthcare staff to ensure that patients are receiving care that is
not only evidenced-based but also a necessary component of their
plan of care. As part of the campaign, national and international
healthcare organizations asked their members to identify tests or
procedures commonly used in their respective fields of practice
whose necessity should be questioned and discussed. Since the
initial launch, Choosing Wisely® has grown exponentially. Today,
19 countries and more than 80 specialty societies are participating
in the initiative, including nursing organizations such as the
American Academy of Nursing, American Association of Critical
Care Nurses and the American Association of Neuroscience
Nurses. Collectively, over 500 recommendations and 1,300 journal
articles have been published.
In 2014, the American Association of Critical Care Nurses
partnered with three other critical care societies as part of the
Critical Care Societies Collaborative to create a list of routine
critical care practices that should be questioned and could even be
considered harmful in some instances. The recommendations are:
1. Don’t order diagnostic tests at regular intervals, but instead
in response to a specific clinical question.
2. Don’t transfuse red blood cells in hemodynamically
stable, non-bleeding patients who have a hemoglobin
concentration greater than 7 g/dL.
3. Don’t initiate parenteral nutrition in an adequately
nourished critically ill patient during the first seven days of
their ICU admission.
4. Don’t deeply sedate mechanically ventilated patients
without a specific indication and daily attempts to lighten
and wean sedation.
5. Don’t continue life support for patients at high risk for death
or severely impaired functional recovery without offering a
comfort care focused option.
In addition to the aforementioned recommendations, the
American Academy of Nursing developed a list of “20 Things
Nurses and Patients Should Question.” Those that are applicable
to neurocritical care include:
1. Don’t let older adults lie in bed or only get up to a chair
during their hospital stay.
2. Don’t use physical restraints with an older hospitalized
3. Don’t wake the patient for routine care unless the patient’s
condition or care specially requires it.
4. Don’t place or maintain a urinary catheter in a patient unless
there is a specific indication to do so.
5. Don’t administer PRN sedative, antipsychotic or hypnotic
medications to prevent and/or treat delirium without first
assessing for, removing and treating the underlying cause of
delirium and using non-pharmacologic delirium prevention
and treatment approaches.
6. Don’t assume a diagnosis of dementia in an older adult
who presents with altered mental status and/or symptoms
of confusion without assessing for delirium or delirium
superimposed on dementia using a brief, sensitive, validated
7. Don’t administer diazepam for muscle spasm following
spine surgery in the elderly.
8. Don’t order formal swallow evaluations in stroke patients
unless they fail their initial swallow screen.
As a constant presence at the bedside, nurses can have an
enormous influence on patient care. Patients and their families
often turn to nurses to ask their thoughts and opinions on
treatments and healthcare decisions. Ideally, if nurses are familiar
with Choosing Wisely®, they will feel empowered to help patients
understand the recommendations, assist patients in asking
questions and feel confident discussing recommendations with
prescribing providers in order to ensure patients are receiving
necessary and evidence based care.
Advanced Practice Registered Nurses (APRNs) can participate
in the Choosing Wisely® initiative by serving as a source of
continuity of care for patients in the ICU, especially in larger
academic medical centers where residents rotate from one service
to another. Some APRN staffing models include 24-hour coverage,
making it possible for them to help significantly decrease the use
of unnecessary testing. In 2015, Vanderbilt University Medical
Center launched an APRN led Choosing Wisely® initiative that
successfully increased clinician awareness and better ordering
practices. Due to the success of the initiative, the Advanced
Practice Nursing Collaborative was created to enable advanced
practice teams at other institutions to participate in implementing
a Choosing Wisely® initiative of their own.
In conclusion, it is our responsibility as nurses to further
disseminate Choosing Wisely® resources and help educate our
peers and colleagues. Both APRNs and staff nurses can promote
awareness and serve as champions to reinforce the goals of
improved ordering practices and decreasing unnecessary tests.
This can be done formally through presentations, flyers, email
communications, or informally by simply encouraging daily
discussions in multidisciplinary rounds.
To learn more about the Choosing Wisely® initiative, please visit
To learn more about the Advanced Practice Nursing Collaborative,
please visit https://ww2.mc.vanderbilt.edu/nursingoap/49500.