Within the healthcare environment, the term ‘routine practice’ is used to describe the care and management that is normally provided to patients with a particular condition. This term is often used interchangeably with standard care, standard practice and standard treatment. The National Cancer Institute in the United States (US) (2012) notes that standard care is also synonymous with best practice, standard medical care and standard of care. These terms relate to the provision of interventions that experts agree are appropriate, accepted and widely used. In contrast to the lack of discourse on the concept
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of routine practice, there is much deliberation on the concept of standard of care.
The legal definition of standard of care is the level at which practitioners serving a particular patient population should practice; for example, patients with similar conditions should receive similar management from practitioners (Sheil & Conrad 2008). A similar legal definition is used within the nursing profession, where there is an expectation that nurses adhere to the standard of care that is expected of them (Miola 2009). Both definitions do not include any criterion indicating the quality of care that should be provided.
Standard of care in clinical research, similar to the legal definition, is defined as the treatment that should be provided to research participants (Nuffield Council on Bioethics 2002, van der Graaf & van Delden 2009). In the context of clinical research there is much debate on what the standard of care comprises, especially among those organisations that make recommendations on ethical principles governing such research.
The Nuffield Council on Bioethics (2002, 2005) categorise standard of care as either universal or non-universal. Universal standard of care is the best treatment available anywhere in the world for a particular illness. It may not be feasible to deliver such a standard of care, due to the economical circumstance of participating countries or a lack of agreement among medical experts on a universal standard of care for that particular illness. Additionally, the means of delivering a universal standard may not exist for reasons other than economic; for example, the configuration of the healthcare service might not be suitable. Instead, a non-universal standard of care may be provided, which is the best treatment provided by the national public health system for that illness.
Other organisations provide an outline of what the standard of care should entail. For example, the Declaration of Helsinki (World Medical Association 2008) describes the standard of care as the best current proven intervention for that illness. Similar, the Council for International Organisations of Medical Sciences (CIOMs) (2002) defines standard of care as the established effective intervention.
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Overall, there is general agreement that the standard of care is the treatment that should be provided to patients with a specific illness, similar to that expected from routine practice. Various terms are used in the literature to describe the standard of care, such as the provision of the best available, the best current, a proven or an established effective treatment. The terms ‘best’, ‘proven’ and ‘established effective’ indicate the quality of treatment provided, with the expectation that this treatment is based on the best evidence.
Within nursing there is also an expectation that routine nursing practice be evidence-based, using evidence from research, clinical guidelines (international, national or local), nursing and medical literature and literature relevant to specialist areas of practice (Davies et al. 2006, Gerrish et al. 2007, Knowles et al. 2010, Profetto-McGrath et al. 2010, Gerrish et al. 2011, Gerrish
et al. 2012). The broader definition of ‘evidence-based’; however, is not solely focused on the best evidence, but the integration of that evidence with clinical expertise, clinician and patient preferences and individual values (Sackett 2002). The Nursing and Midwifery Board of Ireland (2000) code of professional conduct advocate that nurses provide the highest standard of care. The UK Nursing & Midwifery professional code (2008) goes further and expects that this standard of practice and care is underpinned by the best available evidence or best practice.
Clinical practice that is rooted in the best evidence is considered essential in optimizing patient outcomes (Profetto-McGrath et al. 2010). A Cochrane Review (Thomas et al. 1999) investigating the effects of clinical practice guidelines concluded that there was some evidence that practice underpinned by practice guidelines were effective in changing the process and outcome of care provided by professions allied to medicine. The review included 18 studies, and 17 of these related to the nursing profession. Limitations include the inability of the review’s authors to undertake a meta-analysis due to the substantial heterogeneity between studies and the methodological quality of the studies included in the review.
As outlined above, the term routine practice is synonymous with standard of care and will therefore be used throughout this thesis to describe the treatment provided to patients with a specific illness. One of the aims of integrating routine practice with clinical practice guidelines, which are based
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on the best evidence, is to decrease inappropriate variations in practice (Thomas et al. 1999, Chalkidou 2009).