Practice makes perfect

This month the University of West London sees the retirement of Professor Robert Pratt. During his career Robert has distinguished himself in many different areas of life but it is for his involvement and leadership in the early days of the HIV pandemic and for his work in infection prevention and control he is best known to nurses. Robert has throughout his career shown a seamless commitment to developing nursing practice through education and research. In the 1980s Robert brought sense, perspective and compassion to caring for people affected by HIV infection through his educational work and particularly by the publication of his book HIV and AIDS a Foundation for Nursing and Healthcare Practice (Pratt, 2003) now in its fifth edition and known to many simply by the author’s name ‘Pratt’, a rare accolade few academics achieve. In the 1990s Robert and the team in the Richard Wells Research Centre at the University of West London turned their attention to healthcare-associated infections (HCAIs). Through a rigorous and systematic review of the literature the team developed the Epic 1 (Pratt et al, 2001) and then the revised and augmented Epic 2 (Pratt et al, 2007) guidelines for the prevention and control of HCAI. The Epic guidelines have informed and underpinned the comprehensive reductions in methicillin-resistant Staphylococcus aureus (MRSA) and Clostridium difficile infection seen across the UK over the past 10 years. Lives have been saved and the Epic guidelines have been pivotal in turning around what had become a ‘national scandal’ in which countless numbers of people were exposed to the uncontrolled risk of infection when receiving health care. Whether in looking after people with HIV infection or preventing and controlling HCAI, Robert’s work has shown that nursing practice, our practice, counts. In reducing HCAI, are there lessons to be learned that will help us understand how evidence-based best practice can be established and sustained? Implementing evidence-based practice has perhaps more to do with art than science, particularly when there is a lack of evidence or consensus on what best practice looks like. In this potential dither about what needs to be done, less than optimal practice can and does flourish. I believe the Epic guidelines reduced this dither in respect to HCAI. Through the rigorous approach employed by the authors the best available evidence was sourced and developed into clear guidelines; but more than this the research team where actively involved in developing methods for dissemination of the guidelines that went beyond publication alone (Loveday, 2011). Deciding what needs to be done and being clear on what best practice looks like is one thing but there is also a need for clinicians and organizations to have the ability to communicate this to where it matters most; front line clinical practice. This requires not only leadership but active management of clinical practice and patient care. Establishing and sustaining measurable best practice is only achieved when evidenced-based practice is accompanied by credible multiprofessional clinical leadership that is augmented by an organizational response that supports practice. The NHS in England mounted a total organizational response to achieve reductions in HCAIs, in which the setting of measurable infection reduction targets was central to the delivery of the Government’s policy. To achieve these targets hospital boards had to reprioritize their objectives and how they used their financial and material recourses. At a national, organizational and clinical level, clinical leadership informed by the best available evidence played a central role in challenging and changing practice, in a way general management simply could not. This led to a welcome renaissance in the recognition of the clinical rather than the purely managerial role of the director of nursing within NHS hospitals. In controlling HCAI, particularly in hospitals, the public got to the issues before the health professionals did. I think it was remarkable that it was only when there was a crescendo of public and political opinion supported by Government policy did health professionals begin to respond and then only halfheartedly to the risk of HCAI. Many would argue that if it had been left to the health professionals, we would all have had to learn to live with the impact of HCAI on our lives and families. For evidence-based best practice to be established and sustained there are many factors that come into play, however, from our collective experiences of reducing HCAI there seems to be three components that, if aligned, will achieve clinical change. Firstly, knowing what do in terms of best practice; secondly, political and organization commitment and drive to achieve improved clinical performance and finally, practice that takes account of the public voice. Best practice is one thing but we also need to be the best practitioners we can be in our knowledge, skills and values and on this point we need look no further than Emeritus Professor Robert Pratt. BJN