What is best practice?
As new procedures and medicines become available, nurses committed to excellence must regularly update and adapt their practices. The approach known as “best practice” is an important tool in helping nurses provide high-quality care to their patients. Best practice refers to the clinical practices, treatments, and interventions that result in the best possible outcome for the patient and the health care facility providing those services.
The concept of best practice comes from the wider health care community. Interest in this concept has grown as a result of increasing requirements that health care providers control costs and show statistical evidence of the effectiveness of a treatment program. Experts began to recognize that treatment of patients with similar diagnoses differed significantly among practitioners and health care systems and that these differences led to inconsistent patient outcomes. They turned their attention to identifying the care that resulted in the best outcomes for patients and encouraging practitioners to provide that kind of care.
Nurses have been part of this effort all along. The Best Practice Network, until recently an affiliation of nursing organizations whose aim was to help nurses implement best practices, defined best practice as a “plan, action, or service that has been improved and implemented to produce superior outcomes.” In nursing, determining best practice is a process of identifying high-quality nursing practices, analyzing them, and applying them to local nursing practices. It allows nurses to use information from various sources — not only research and textbooks, but also colleagues and other experts. The best practice approach is generally a team effort, which provides a structure for deciding when and how to use these sources of information.
This process may seem time-consuming and of questionable value to nurses who have clinical experience or who have recently completed educational programs. Yet, even these nurses encounter everyday questions for which there are no ready answers. A best practice approach gives nurses the tools to answer clinical questions intelligently, effectively, and — with a little practice — promptly.
The process of identifying excellent nursing care practices, knowing how to measure them, and putting them to work in clinical practice helps to delineate exactly how nurses contribute to better patient outcomes and gives nurses evidence of the value of their practice. Health care facilities benefit because consistent care based on the most current evidence is efficient and cost-effective. (See Building best practices, page 2.)
Identifying best practices
How do we know what a best practice is? The process begins with understanding the common sources of information available to nurses: research data, personal experience, and expert opinion. (See Research and nursing, page 2.)
One might be tempted to rely entirely on research-based information. However, such information has several disadvantages. The data are limited in amount and scope. Many studies produce inconclusive results and require further research; others may not address the specific problem the clinician is attempting to solve. Data from research journals can be highly technical and difficult to implement in clinical practice. Finally, the journals that publish such data are expensive and, if obtained, nurses may not have the time to read them.
A nurse’s own experience or that of her colleagues is less reliable than research because a single person can be influenced as much by preconceptions as by objective observations. For example, if a nurse believes that a certain medication is the most effective,
her enthusiasm may affect how patients respond to the medicine. Furthermore, even the most skilled practitioner may not notice that a large percentage of her patients don’t respond well. This bias is part of human nature, and it can cloud any practitioner’s judgment. Best practice provides other sources of information and a structure for implementing that knowledge in one’s practice.
her enthusiasm may affect how patients respond to the medicine. Furthermore, even the most skilled practitioner may not notice that a large percentage of her patients don’t respond well. This bias is part of human nature, and it can cloud any practitioner’s judgment. Best practice provides other sources of information and a structure for implementing that knowledge in one’s practice.
Building best practices
Identifying and developing best practices is a team effort. Listed here are five basic steps for building best practices in your facility.
Limit the size of the team to 8 or fewer members. Include those who work most closely with the users of the service or the users themselves, and be sure to get a commitment from the members during the initial planning meeting. Hold members accountable to their commitment; eliminate those who don’t show up, instead utilize them as consultants.
Communicate clearly the reason for creating the team; clarify the goals, the problem, and the process for improvement to avoid different perceptions of why the team has assembled.
Examine the issue, looking at the positive and negative aspects of the program. Gather information using facts, statistics, experiences, examples, analogies, and expert feedback. Analyze the data for your program and others to identify gaps in care.
Determine specific measurable objectives, indicators to be measured, and timelines.
Benchmark, or compare your results against other services and programs.
Research and nursing
Research is the foundation on which all sciences are based. Its reliance on observations made in a controlled setting limits confusion over which factors actually produce the results. Health care professionals have long recognized the importance of research in the laboratory setting, but recently they have begun to develop ways to make research information more useful in the clinical setting.
Evidence-based nursing is the term used to describe nursing practice based on information obtained from research. For example, a nurse’s belief that a certain drug is more effective for pain relief than others may be based on previous experience with that drug. But other factors could be contributing to pain relief, such as the route of administration or the amount of time the nurse spends assessing the patient. Perhaps the drugs produce similar analgesia, but the nurse’s approach to care affects the patient’s response. Research data help the nurse make evidence-based decisions in choosing one drug over another, and they may provide insight into treatment for a patient who doesn’t respond to a medication. Finally, research information tends to be more current than information published in textbooks.
Benchmarking
In addition to an evidence-based approach, benchmarking is one process for identifying sources of best practice information. This collaborative, ongoing process has been used in many fields for centuries; the term originated with the reference marks that craftsmen noted on their workbenches. Today, a benchmark is a measure of performance that serves as a standard for evaluating other results. The concept came to health care in the mid-1990s with the need to increase efficiency without sacrificing quality of care. Health care facilities had to find the most effective management approaches possible. Benchmarking is especially useful for administrative nursing
concerns, such as cost and nursing hours required per patient.
concerns, such as cost and nursing hours required per patient.
Traditionally, benchmarking is done by a team of members from different professions and departments in a hospital or other health care facility. A critical factor in successful benchmarking is careful consideration of the benchmarks that are used and how they were achieved. Without this focus, benchmarks become rules to be followed without understanding the reasons. Thus, successful benchmarking is an ongoing process of planning, data collection, analysis of processes and practices, and implementation for improvement. (See Benchmarking for best practices.)
Planning
The first step in benchmarking is for the team to identify clear, concrete, specific goals for patients and the facility. Examples include decreased length of hospital stay, decreased complication rates, and increased patient and family satisfaction.
With goals established, the team next searches for appropriate outcome measures for the identified goals — length of stay statistics, for example. The focus here is external; that is, on measures used at other facilities. Benchmarks aren’t always available, especially for nursing-related outcomes, such as pain management and patient and family satisfaction with care. Identifying these gaps is part of delineating nursing’s unique contribution to patient care outcomes. If no studies exist for a desired benchmark, the team’s study can be the first to set the benchmark.
Collecting data
After deciding on appropriate benchmarks, the team’s next step is to find them. Formulating a plan and a timetable for collecting and analyzing the data can help the team avoid becoming bogged down at this stage. Government Web sites, hospital and professional organization Web sites, and benchmarking collaboratives, such as the University Health System Consortium, can all be good sources of data. Research data can be obtained through traditional means, such as going to a medical library or using Internet sources such as PubMed, a database of published health care literature maintained by the National Library of Medicine.
Innovative PracticeBenchmarking for best practices
Your facility can develop a benchmarking worksheet as a tool to guide the process of benchmarking, keep track of the results, and document accomplishments. When you have identified a goal, complete the following steps on the worksheet and document your findings.
Find two or three benchmarks that can be used as measures for the stated goal and can be compared across systems. Benchmark categories include cost, clinical outcomes, patient satisfaction, and functional health status.
Select the resources you’ll use to determine best practices. This includes identifying the experts in the field internally and externally, researching and analyzing data internally and externally, looking at national averages or standards and the best outcomes, and examining the published literature (research reports).
Formulate a data collection plan, including who will collect the data. Establish a timeline for data collection, analysis, and documentation.
Measure your own performance against benchmarks, comparing your facility’s outcomes against national standards or best outcomes.
Identify practices that produce best results. Studying the differences between those “best” processes and your own could provide innovative strategies to introduce changes.
Implement new or revised practices. This step could include establishing or updating standardized orders or changing the admission process.
After implementing a best practice, collect data to determine if outcomes have improved or worsened.
Analyzing processes and practices
The team’s next step is to compare the collected data to the information about its own facility to identify gaps between the two. After identifying a difference, the team analyzes the processes that produced the best results and tries to delineate how they differ
from local practices. How were shorter patient stays or improved patient satisfaction achieved? Which nursing interventions resulted in fewer complications? How often were they done and when? These kinds of questions are an important part of understanding how to achieve similar results.
from local practices. How were shorter patient stays or improved patient satisfaction achieved? Which nursing interventions resulted in fewer complications? How often were they done and when? These kinds of questions are an important part of understanding how to achieve similar results.
Criticisms of evidence-based practice
Obstacles to promoting and using research in nursing commonly stem from misunderstandings about the purpose or process. Common criticisms of evidence-based practice are that it:
disregards individual patient care and leads to “cookbook” nursing
will have a detrimental effect on the quality of patient care to save costs
can’t be beneficial due to clinical trials and meta-analyses being unpractical and too laborious for the clinical setting
creates unclear communication from nursing leaders about the process
has no quality standards for conducting research in nursing
lacks confidence in nurses’ skill to conduct research
creates an unwillingness of facilities to fund research and implement costly changes in practice based on evidence
has a narrow conception of evidence, overlooking important health care information.
Implementing for improvement
Finally, the facility implements changes. Sometimes, repeating exactly what was done at another facility isn’t feasible, for example, because the patient populations or staff differ. In such cases, the team must be innovative and adapt the process to the existing environment.
Because the changes are new, the team must regularly evaluate their impact. This means monitoring patient outcomes to find out whether the new procedures improve these outcomes and if the changes created new problems. Inevitably, refinements and adjustments are necessary, which is why benchmarking is an ongoing process.
Evidence-based nursing practice
Nurses can also use benchmarks to compare, measure, and evaluate their own practice outcomes in evidence-based nursing practice. Evidence-based practice is nursing practice built on information obtained from research. For example, perhaps you were taught in nursing school that turning a patient every 2 hours was the way to prevent pressure ulcers. However, in practice you find that this alone doesn’t seem to prevent ulcers from developing in your patients. After reading current research on the subject, you know that a patient’s nutritional status is also important. This evidence leads you to encourage increased intake of protein as one of your nursing interventions.
Traditionally, nurses haven’t regularly used research as a basis for practice. (See Criticisms of evidence-based practice.) A survey of staff nurses about how often they used various sources of knowledge for their practice revealed that the most common source was what colleagues or physicians were doing or what they had been taught in nursing school (despite the fact that the surveyed nurses had been out of nursing school for an average of 18 years). Of those who did read about research in journals, about one-third didn’t read the research itself but others’ reports on it (known as secondary sources).
Of course, it can be daunting for a nurse to consider whether everything she does in her nursing practice is evidence based. However, the idea of evidence-based practice is an ongoing concern, like all aspects of best practice. As questions arise in clinical practice, research is one avenue for answers. With a little practice in finding articles that relate to a question and in making sure that the source is a high-quality one, nurses usually find the straightforward process of implementing evidence-based changes rewarding.
Moving toward evidence-based nursing
The basic steps involved in evidence-based nursing practice resemble those of benchmarking: formulating a clinical question, searching for peer-reviewed articles on that clinical question, critically evaluating and comparing the articles, applying the information from the articles, and evaluating the outcome of the changes made in local practice.
Formulating the clinical question
The clinical question may develop from questions that arise in your practice or from an area in which you want to increase awareness. For example, you may wonder which type of adhesive is most irritating to skin. The manufacturer provides some information, but you know this information isn’t entirely objective, so you decide to investigate further.
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