International Journal of Nursing Practice 1999; 5: 100–105

INTRODUCTIONWe are living in a time much different to the early 20thcentury, a time when change is an everyday occurrenceand our diverse social worlds embrace a variety of reali-ties and positionalities.1 Both the tempo and tenor ofchange in wider society mirror changes in the health-caresystem.Aspects of health care affected by change are thosethat are underpinned by medical–scientific progress and,more recently, health-care policies affected by beliefsystems such as economic rationalism. As part of thesesocietal changes, the dominant values associated with late19th and early 20th century social development, that ismodernism, are being contested by alternative views.Thisdoes not suggest that the values associated with moder-nity have disappeared, rather it suggests we now have the-

oretical perspectives that allow critique of such a mod-ernist worldview. Currently, modernist values such as cer-tainty, objectivity and unitary belief are under challenge.Such challenges are mounted by a contest between thetwo worldviews represented by modernity and its cri-tique, postmodernity. Many of these challenges havefocused on the ways in which the world is repre-sented within modernist language and culture. Such a lan-guage use is represented in the discussion concerning bestpractice.

This paper offers a critique of the concept ‘best prac-tice’ and the modernist discourse on which it is based.Thepaper begins with a discussion of how dominant ideasassociated with modernity are linked to power and howthese influence the way we understand our social world.Features of modernity are outlined and their associationwith health care and health-care delivery is discussed. Acritique of best practice and the implications for nurses’work is presented. Finally, suggestions offering a wayforward are provided.

✠ R E S E A R C H P A P E R ✠

Best practice: What it is and what it is not

Colleen Smith RN, DipT(NsEd), BEd, MEdSenior Lecturer, University of South Australia, Adelaide, South Australia, Australia

Frances Sutton RN, RPN, DipT(NsEd), BEd, MEd AdminAssociate Professor, University of South Australia, Adelaide, South Australia, Australia

Accepted for publication September 1998

Smith C, Sutton F. International Journal of Nursing Practice 1999; 5: 100–105Best practice:What it is and what it is not

This paper offers a poststructural critique of the concept of best practice and suggests that those practising best practiceseek to reinforce modernist notions of health care and health-care delivery. Modernist notions limit possibilities for health-care workers, including nurses, as well as limiting the care delivered to clients. In turn, these mask various outcomes forclients and health-care workers. This paper explores the concept of best practice and the discourse on which it is basedand offers an alternative perspective on which high quality health-care services can be developed.

Key words: best practice; health-care delivery; modernist discourse; poststructural critique; quality health care.

Correspondence: C. Smith, 18 Immanuel Drive, Salisbury Heights,South Australia 5109, Australia. Fax: +61 08 3026657;Email: <colleen.smith@unisa.edu.au>

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DOMINANT DISCOURSE: A WAY OF THINKING

Livingstone presents a number of ideas pertaining to howwe think about and come to know the world.2 He suggeststhat:

(1) There is a dominant way of thinking and actingthat might be called a ‘dominant discourse’.

(2) This dominant discourse is composed of anumber of elements which construct the dominant dis-course’s internal logic and maintain its power.

(3) Alternative ways of thinking and acting areactively discouraged and delegitimized by the internallogic of the dominant discourse.

(4) It is necessary to act at each of the levels at whichthis dominance is maintained if we are to develop alter-nate way(s) forward.

The modernist discourse is the dominant way of think-ing and acting that directs current health-care practices.The modernist discourse discourages alternative ways ofthinking and acting and reacts to these alternatives asthough they are irrational, nonscientific and thereforeirrelevant to today’s world. Consequently, the dominantdiscourse becomes embedded into our everyday thinkingand acting and becomes a taken for granted reality thatshapes the way we come to understand the world. Con-temporary thoughts and ideas seek to reinforce this dom-inant discourse, thus perpetuating its existence andmaintaining its dominance and power.

The authors of this paper suggest that present thoughtsand ideas pertaining to best practice reinforce modernistnotions of healthcare. As a consequence, individualsworking within healthcare take for granted the premiseson which such reality is based and do not look for alter-natives. In accepting this reality, individuals begin to viewthings and to make decisions using the language and ideasassociated with the modernist discourse. Such modernistnotions of healthcare and health delivery limit possibilitiesfor health-care workers, including nurses.

Before engaging in a critique of best practice, weexamine what is meant by the term ‘modern’, identify thefeatures of a modernist discourse and examine how thesefeatures present in the current health-care system.

MODERNIST NOTIONS OF HEALTHCARE AND HEALTH CARE DELIVERY

Today’s health-care system is undergoing rapid change as we strive for improvements in the health of all Australian people. Faced with a rapidly ageing population,

an increase in consumer expectations for health servicesand escalating costs of health technology, new mechanismsto organize, finance and deliver health services are beingintroduced. Central elements of these changes includeincreasing the efficiency and effectiveness of service provision, public accountability, quality assurance andoutcome measures. These elements all have been instru-mental in introducing changes such as the amalgamationof health-care services, privatization and outsourcing ofservices, devolution and internal restructuring as well as deinstitutionalization. These changes, combined withexpanding technology, are instrumental in shaping the wayhealthcare is financed and delivered. Sarup3 and Fox4 linkthe beginning of modern times with the Enlightenmentperiod of the 18th century.This period was characterizedby a shift from mythical thinking to rational thought basedon reasoning. Giddens roughly equates modernity to theindustrialized world, although he does imply that indus-trialization is only one aspect of modernity.5 Regardless ofwhen the periodization of modernity began, there arecertain attributes of modern societies that have had animpact on our current health-care system. Fox highlightsideas of linear progress, absolute truths, rationalizationand standardization of knowledge production as consti-tuting the period of modernization.4 Today’s health-caresystem continues to reflect the factory production line ofindustrial times, albeit in a more sophisticated manner.Individuals working in organizations carry out prescribedroles and tasks, guided by set rules and regulations.This approach creates societal order and allows for thecoordination of human actions on a massive scale. Rule-driven processes and procedures are efficient and effec-tive management tools that can be subjected to scientificanalysis.

Current information technology systems provideefficient means of gathering, storing and retrieving infor-mation and therefore perform as surveyors of humanaction. Foucault equates the notion of surveillance with amode of power called panopticism that represents a cir-cular building of prison cells all watched from a centraltower. He equates the panopticism to a ‘. . . machine inwhich everyone is caught and which no one knows’(p. 9).6 Our health-care system has technological surveil-lance mechanisms used to monitor organizational effec-tiveness and allow comparisons between organizations.These systems support mechanisms such as casemix, crit-ical pathways, care mapping, case management and qualityaudits. In essence, information technology provides the

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‘energy chip’ enabling the modernist discourse to surviveand dominate in present day society.

Titles are designated to health-care providers accord-ing to their functional roles. Within each of these groupsfurther differentiation occurs in the form of specializa-tion.This approach subdivides work practices into specificfields performed by workers. These workers, includingnurses, acquire expertise from working in a specific fieldand are responsible for the care they provide while theclient is under their specialist service. This division oflabour also allows opportunities for direct surveillance of the workforce. The health-care system has seen a rapid accumulation of knowledge and rhetoric associatedwith obtaining and maintaining quality health care. Arm-strong comments, ‘the rhetoric of economic rationalismand efficiency will be supplemented by the rhetoric ofmanagerialism,‘best practice’, ‘benchmarking’, risk man-agement and total quality management’(p. 18).7 This lan-guage and associated knowledge becomes part of the dominant discourse influencing health professionalsand thus becomes ingrained into the text and language of policy makers. All this is incomprehensible to thelayperson who is then unable to have input into thesedevelopments.

Rationalist approaches remain an integral part of ourmodern world particularly in the health-care arena. His-torically rational arguments are premised on the model of logical empiricism derived from the influence ofscience and medicine. In recent years this influence has not diminished, rather it continues to reflect the increas-ing dominance of a political ideology driven by economicrationalism. Livingstone2 believes economic rationalism isa reductionist approach to health-care management. Itrelies on a rational way of thinking and analysis to explainand predict behaviour. In doing this it ignores alterna-tives, therefore excluding vast amounts of information.Efficiency is about economic performance including profitmaking and capital accumulation.This ideology has meantthat economic values are at the forefront of policy decision making and have taken precedence over socialvalues. Thus resources are directed toward acquiringefficient economic systems rather than toward the peopleand their practices.

BEST PRACTICE:WHAT IT IS ANDWHAT IT IS NOT

Best practice has its roots embedded in the quality dis-course and modernist ideas that have dominated the health-

care system. According to the Australian Best PracticeDemonstration Program ‘the pursuit of best practice is the pursuit of world class performance . . . a comprehen-sive, integrated and cooperative approach to the con-tinuous improvement of all facets of an organisation’soperations’(p. 1).8

There are many principles acknowledged as driving thebest practice movement.These espouse to involve contri-bution from employees at all levels with the primary focuson identifying, responding to and satisfying consumerneeds. Within this model such elements as open com-munication, collaboration, and consultative mechanismare highly valued. The emphasis here intends to be onhumankind and the meaning individuals contribute to bestpractice performance.Adhering to these principles allowsorganizations to match and base improvements in theirperformance on identified international best practice.Thisserves to ensure they are competitive in the internationalmarket. Organizations do this by using both qualitativeand quantitative indicators and benchmarking.

Benchmarking is a process of identifying and imple-menting best practice. It involves measuring one’s perfor-mance and practices against leaders. It is ‘an objective,ongoing search for best practices and processes, (and) isan essential tool for organizations committed to achievingworld class standards of performance’(p. 5).8 It is a sys-tematic approach that identifies areas of best practiceoutside an organization and incorporates these in theinternal activities of an organization for the purpose ofcontinuous improvement.

Health-care organizations use benchmarking to sub-stantiate improvement in performance. A particular group of key players identify and adopt best practices withthe expectation there will be sustained superior perfor-mance. A close examination reveals that this process cannever capture reality because no two organizations are the same. For instance, identifying and adopting best prac-tice from another organization does not allow for thediversity of social organizations nor the context in whichthey function. It does not give recognition to the histori-cal, social, cultural, and political milieu in which bestpractice develops and matures. It does not consider themultiplicity of ideas and the variations of social worlds.Rather, it is searching for a global, totalizing practice thatis ‘best’.

We should not uncritically accept best practices fromanother organization, as success in one organization doesnot mean success in another. To do so supports the dom-

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inant system of values and meanings of the modernist dis-course. Being critical requires question to be asked, ques-tions pertaining to who ascertains it is best practice,and for what purpose? How are meanings about best practice created and maintained? How is power exer-cised and experienced and whose interests are beingserved by adopting this as best practice? These are impor-tant questions if nurses and health-care professionals areto challenge the dominant value systems that direct theirpractices.

Uncritically adopting best practices is inadequate unlessit addresses the power relationships that shape the con-sciousness of the players. Failure to expose the power rela-tionships between employer, employee, consumers andthe organization(s) to whom best practice is benchmarkedignores the social context in which ‘particular’ best prac-tices are located. Further it reflects the power of domi-nant groups to shape its direction.We need to rememberthat individual meaning and actions are located by thesocial context in which they operate. As such, beforeadopting best practice it is necessary to recognize andexplore historically how an organizations’ best practiceevolved and the cultural means of production. Further weneed to acknowledge there are differing value systems andthus different positioning of the service user, the serviceprovider and the organization that provides the service.

Becoming the best also has connotations of competitionand power struggles over limited resources. The processof searching for best practice involves identifying others,with similar practices. In identifying and adopting bestpractice from other organisations it is assumed that all willbe revealed. In today’s society where market competitionis ripe, can we assume others will share all informationabout their practices? This is further questioned whenorganisations are competing in the market place forsimilar client groups and when resources are limited.

Language is a powerful medium through which wecome to understand, construct and express our world-views. The term ‘best practice’ invokes a sense of stasiswith having reached an end particularly as ‘best’ implieshaving reached a pinnacle of performance. Maybe lan-guage that incorporates the use of the term ‘better prac-tice’ is more indicative of reality as it indicates a practicethat is progressive and dynamic. It indicates that practiceis continually evolving and improving rather that havingreached a pinnacle of performance.

Armstrong urges us to be wary of ‘the language of thequality movement being applied to our hospital system’.7

Armstrong stresses the need ‘to expose the reality behindthe rhetoric so that we are not deceived into thinking thatit has anything to do with quality of patient care’.7 Arm-strong further indicates that we need to fight for realquality in health in the future not the illusionary qualityof the management consultants and the cost-cutting forcesof the benchmarkers’.7

In adopting a postmodern way of thinking that values amultiplicity of view and ideas, we argue, best practice isnot about a search for certainty or a single practice that isbest. It is not about having reached a pinnacle of per-formance or uncritically accepting and replacing one setof structures for another. To search for best practice, anduse this as an organizational benchmark, is clearly a searchfor certainty, a search for a unitary practice; all tenets ofmodernist thinking.

BEST PRACTICE: IMPLICATIONS FORNURSES’ WORK

What does best practice mean in today’s economicclimate? What does best practice mean for the future ofour health-care service and nurses’ work? We contend thatthe best practice movement has been, and will continueto be, instrumental in producing organizational change.

Many health services are being privatized or contractedout through competitive tendering. Presently, this involvesdomestic or housekeeping services such as catering, clean-ing and laundry. Kermode et al. believe that the movementtoward privatization could mean that nurses are morelikely to become private-sector nurses.9 They also believethat, in the future, nursing and medical services will becontracted out and the government will then be thefunder of services. In South Australia, the South AustralianHealth Commission is already engaged in strategies whichreflect a trend to this orientation in health-care provision.What we may see is, ‘. . . nurses and/or groups of nursestendering for caseloads on a contractual, self-employedbasis and then subcontract out services to other healthworkers’,9 with the potential to alter nursing work andthe nursing workforce as services are then provided by apotentially cheaper labour source.The outcome of priva-tization could thus see social impacts associated withredundancies, reduced pay and conditions, heavier work-loads, less work hour flexibility and less job security.

Best practice fails to examine and explicate the socialstructures shaping individuals. Further, best practice failsto explicate the competitive nature of the market place andthe effect this competition has on organizations competing

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for similar clientele and resources. Nurses must resistsome changes in modernist health care because thesechanges often have unquestioned shadows from previouspractices. For example, there have always been competingdiscourses evident in the health-care system. Suchcompeting discourses emerge from the various disciplinesworking within the system and the dominance of medical–scientific discourses.While, for the greater part of the 20thcentury these discourses have held sway, such discoursesare not the major voices heard within the debates over bestpractice and ‘new’ ways of providing healthcare. Take,for example, the scenario previously outlined by Kermodeet al. in which nurses, with privatized care, becomeautonomous providers of health-care services to clientgroups.9 Now, it is possible to view nurses workingindependently in the provision of care as a positive effect.Indeed, many of these practices exist in the ultimately‘privatized’ health-care services in the United States ofAmerica (USA). There, nurses have argued that they canprovide cheaper, cost-effective health-care services tosome client groups while also ensuring consumersatisfaction.10

But, such an emphasis has meant that nurses largelyprovide services for ‘vulnerable’ and ‘under-served’ pop-ulations, the low tech, low status,‘unsexy’ end of medicalcare. We would contend that, since the organization ofhealthcare into hospitals and similar organisations6 nurseshave, to their detriment, provided the alternative voice inthe health-care system. These alternative nursing prac-tices, underpinned by values enshrined in holism andcaring ideologies, have valiantly attempted to humanizethe effects of medical science on patients’ experience ofthe health-care system. Such ambiguities have imposed aburden on nurses’ work. The silencing of these humaniz-ing effects is the context which nurses struggle againsteach day.We would argue there is a similar contest in evi-dence between the discourses of best practice and nursingdiscourses today. Nurses are now constituted as ‘best’practitioners, incorporating modernist practices into theirhumanist belief systems.The effect of such incorporationis, as with the contest with medical science, that nurseshave set out to humanize the effects of economic ratio-nalism on the patients for whom they care.

In the USA, nurses’ endeavours to humanize health carehas led to the development of nurses as case managers andcare coordinators, working to ensure patients receivecare, financially supported by Health Maintenance Organ-izations (HMO) or medical insurance companies. As

such, nurses work to contain the costs of care, audit thecare costs and ensure through ‘managed care’ that thepatient receives the best care they can afford (well, whatthe insurance company will allow them to afford). Somenurses work for insurance companies or HMOs, makingsure that clients do not receive ‘more’ medical care thanHMOs deem necessary. In this case, as nurses once were‘the eyes’ of medical science, they are now ‘the eyes’ formedical insurance companies. While nurses may get agreat deal of satisfaction from such ‘management’ prac-tices, the unexamined conditions of a previous time are still embedded in such practices. While there are dif-ferences between the provision of health services in Australia and the USA, Western countries tend to followthe broad directions established by the USA (for example,as in the instance of casemix and diagnostic relatedgroups).This ought to signal the need to be wary of otherinitiatives in healthcare evident in the USA as such initia-tives may be implemented here, albeit based on differentrationale.

We suggest that, again, nurses are being co-opted by a dominant discourse, not under their control, to work in ways counter to, and in contradiction of, their ownespoused discursive frameworks. Such contradictions actto silence the nursing voice again. Similar conditionsattend to practices such as critical pathway variance analy-sis and care mapping. Our challenge to nurses using suchpractices is that, by so doing, nurses and nursing maskfrom consumers the full effects of economic rationalismon care.A similar effect comes from nurses providing careto groups of people who do not have access to healthcare.The question remains, should nurses continue to supporta system that continually fails to address the needs of itsclient populations? Should we accept the crumbs such asystem hands out to us, or should we challenge the dis-courses of economic rationalism as inappropriate, nomatter what is definitive of ‘best’ care or best practice(when it is obvious they are not)?

A WAY FORWARDIn suggesting alternatives, the authors see that a wayforward is:

• Not to privilege the current modernist reductionistapproach to best practice.Thus best practice should notbe about a search for certainty, a search for a singlepractice that is best, having reached a pinnacle of per-formance, uncritically accepting and replacing one setof structures for another.

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struct this complex concept. Players must engage indebate and be willing to have their practices scrutinized.Best practice must be subjected to ongoing critique toexpose the gaps, silences and ambiguities that render itproblematic.

REFERENCES1 Kenway J,Watkins P. Nurses, Power Politics and Post Modernity.

Armidale: University of New England Press, 1994.2 Livingstone C. Crisis, understanding, planning. Health Issues.

1995; 43: 10–13.3 Sarup M. Identity, Culture and the Postmodern World. Edin-

burgh: Edinburgh University Press, 1996.4 Fox N. Postmodernism, Sociology and Health. Buckingham:

Open University Press, 1993.5 Giddens A. The Nature of Modernity. In: Cassell P (ed.).

The Giddens Reader. Hampshire: The Macmillan Press Ltd.1993; 284–316

6 Foucault M. The Birth of the Clinic. London:Tavistock, 1971.7 Armstrong J. Pressures in the public health system:A union

perspective. Health Issues, 1995; 17: 17–198 Australian Best Practice Demonstration Program. What is

Best Practice? Canberra: Australian Government Publishers,1991.

9 Kermode S, Emmanuel N, Brown C. A critical overview ofcurrent public policy: Trends and their implications fornursing. Collegian 1994; 1: 14–23

10 Padgett S. Dilemmas of caring in a corporate context:A cri-tique of nursing case management. Advances in NursingScience 1998; 20: 1–12.

• To identify espoused values and compare these with theenacted values to search for contradictions and ambi-guities. In so doing, nurses must accept that contradic-tions and tensions will always be present.

• To recognise that there are multiple ways of knowingand multiple strategies for action, thus nurses mustavoid replacing one set of certainties with another set.

• To remember that ‘best’ is coupled with modernistnotions of progress and the belief that progress is good.

• To continue to critique best practice and understandthe dominant discourses that drive and contribute tomaintenance of the best practice movement.

CONCLUSION The meaning and principles of best practice will alway bein transition. Best practice will always mean a variety ofthings to a variety of people and will be implemented andpractised equally well by different social players. Thisvariety will reflect the multiple positioning of the subjectswhose interests best practice is serving. Thus, best prac-tice is not a neutral state that can be defined, measuredand empirically verified. Rather, it is a practice thatinvolves many players and many positions and serves manypurposes. Each of the players brings to the process andpractice moral, ethical, social, political and historicalimperatives. To ensure best practice does not becomeanother catch phrase reflective of a particular era inhistory, nurses must continue to deconstruct and recon-