‘Best practice’: Who says?

The term ‘best practice’ is one that is seen reasonably frequently in relation to diabetes care, as well as in other health-related contexts. It appears that the use of the term is increasing; indeed, there have been whole study days devoted to best practice in diabetes care recently. Like many other concepts that are difficult to define, such as ‘quality of life’, we all think we know what it means. However, we often discover that our perception of what best practice is differs from that of others.

For instance, how often have you read an article purporting to be describing best practice in a particular area only to discover that you do not agree with what has been done? Or, having attended a study day supposedly describing best practice, have you ever thought that yours is better?

This raises the question of who decides what best practice is. Of course, in some circumstances, best practice is clear – there are national guidelines, standards and recommendations for care, for instance. These guidelines have almost invariably been developed, at least in part, from evidence acquired from high-quality research studies and from expert opinions. However, the application of these guidelines, as well as the results of other high-quality research, is usually called evidence-based practice, rather than best practice.

Unfortunately, much of what diabetes nurses do is practised without the benefit of the results of randomised controlled trials or any other research study to guide it. When individuals or teams of diabetes healthcare professionals have a good idea, implement it and then describe the intervention in some way, via either a written article or a presentation, the idea may be labelled ‘best practice’, even when there is little to support the claim.

On occasion, individuals themselves label a presentation or a written account of a project as best practice. This is very rarely done with intent to mislead; it usually occurs when individuals view their work as their best practice and, rightly, judge it to be an improvement on their previous ways of practicing.

However, if it is accepted that the term ‘best practice’ is one that is used when evidence is missing or limited and is a judgement, it surely is logical that there is a consensus of expert opinions about what constitutes best practice, otherwise the term becomes meaningless. An alternative to a consensus would be standards or quality criteria to measure the practice initiative against.

A solution?
The problem may be solved if individuals and teams used the term ‘good practice’ when describing their service developments. After all,  good practice can be based on principles. For example, it could be a start to identify the expected outcomes of the work and relate these to current thinking in policy documents on what is desirable.

Describing the underlying principles is also appropriate. Even if there is no intention to formally disseminate the work to a wider audience, there is value in doing this (for example, to answer questions posed by management, students or colleagues).

However developments in care are described, it is important that we all take care to ensure that we use terms like ‘evidence-based’, ‘best’ and ‘good’ practice carefully. We need to search for similar initiatives and compare our work with these, and we must also be constantly open to our practice being challenged, discussed, analysed and evaluated. One way, perhaps, of ensuring that claims we make about something being best practice are valid is thinking how we might answer the question ‘Who says?’