Clinical practice benchmarking is a new quality improvement benchmarking approach that involves structured learning from others in order to improve, accepting the subjective nature of health care. Evaluative research of clinical practice benchmarking requires mixed methods, quantitative and qualitative. This challenges the current reliance upon quantitative consideration of the effectiveness of quality improvement approaches. A worked quantitative example is provided and demonstrates that descriptive statistics support comparison activity only. It rejects the value of inferential statistics, since benchmark scores relate to subjective statements. Therefore, inter-rater reliability is poor and it is not possible to directly attribute any change in clinical practice benchmark scores to actual changes in practice. Following the quantitative analysis, a qualitative research study was undertaken from an interpretative perspective to evaluate the effectiveness of clinical practice benchmarking as a quality improvement approach. Particular emphasis was given to exploring the organisational factors that support its effectiveness. Data were gathered through semi-standardised interviews of nursing leaders of local paediatric benchmarking activity and frontline nurses, with rigour ensured through reflexivity and a critical approach to the analysis. The main empirical contribution of this work provided new knowledge about nurses' understanding of clinical practice benchmarking. They defined it as using all evidence to agree best practice, focusing upon collaboration to support sharing, rather than competition. The findings identified the organisational factors that ensured the effectiveness of clinical practice benchmarking. The main enablers were motivation of those involved and supportive leadership, underpinned by an organisation that promotes learning and innovation. This research provides compelling evidence that clinical practice benchmarking is an effective approach to quality improvement in health care. However, it requires acceptance of the importance of the subjective nature of health care and the necessity for qualitative approaches to evaluation. Methodological insights from this study also inform future evaluative research.

The study answers the question: 'How can nurses' properly considered decisions relating to patient care be demonstrated?' Nurses in the United Kingdom have a professional requirement to demonstrate': the properly considered clinical decisions relating to patient care' (UKCC, 1994; NMC, 2002). However, their decisionmaking has been reported as complex and poorly understood, and apart from nursing records, little evidence exists to demonstrate their decisions. The development of the nurses' role as a decision-maker is traced from an origin in Nightingale's text (1860) through to the present day. This role is shaped by organisational, nursing and medical profession influences. Having established that nurses have a role as decision-makers, a conceptual framework is used to examine different explanations about the decision process, outcome, context and how decisions are made. Before undertaking fieldwork, a survey of nurses' decision-making in general medical and surgical wards was conducted. The findings were compared with the conceptual framework to generate questions and avenues for enquiry. An ethnographic study was undertaken in 1999 - 2000 in four general medical wards in two English provincial NHS Trusts with registered nurses (general). A model of decision-making was developed as a mid range theoretical explanation of how they made decisions. This involved a narrative based approach in which nurses generated an account (narrative) of knowing a patient and used this to identify needs. The patient was known in a narrative through three categories of information: nursing, management and medical. These categories were constructed through nurses' information seeking and processing using a tripartite conceptual lens. These facets correspond to different aspects of the nurse's role as a carer, care manager and medical assistant. The patient is known in three ways in a narrative, as a person to care for, an object to be managed, and as a medical case. An oral tradition surrounded its use, and nursing records were not central to decision-making. The narrative was used to make decisions and influence medical decisions. Once it was established how nurses made decisions, a method was developed to show how they could demonstrate their properly considered clinical decisions relating to patient care. This involved using the narrative based decision-making model as an analytical framework applied to nurse decision narratives. Narrative based decisionmaking offers a development of existing descriptive theoretical accounts and new explanations of some features of the decision process. This particularly includes the use of personal note sheets, the role of judgements and the cycle of communicating the narrative to nurses and its subsequent development as a process of developing an explanation of how the patient is known. Having addressed how nurses can demonstrate their properly considered clinical decisions relating to patient care, conclusions are drawn and implications explored in relation to practice, professional regulation, education and method. Recommendations include a challenge to the assumption about decision-making underpinning existing NMC guidance on recordkeeping, and the need to recognise diversity of decision-making practice across different nursing sub-groups. The narrative revealed nurses' ways of constructing knowing patients and rendering this visible. Nurses' not only have a duty, but also a need, to demonstrate decisions so that they can render visible what it is they are and do.