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Acta Paulista de Enfermagem

On-line version ISSN 1982-0194

Acta paul. enferm. vol.25 no.5 São Paulo  2012 



Variability of clinical practice in nursing: an integrative review


Variabilidad de la práctica clínica en enfermería, una revisión integradora



José Fernández-de-MayaI; Miguel Richart-MartínezII

IMasters in Nursing (MSN). Supervisor of Day Hospital and Home Hospitalization. Vinalopó Hospital- Torrevieja Hospital, Alicante - Spain
IIDirector of the Nursing Department. University of Alicante - Spain

Corresponding Author




OBJECTIVE: The objective of this literature review was to examine what has been published about variability in clinical practice from the focus of nursing.
METHODS: We performed a literature search in the principal international databases, selecting those most relevant works.
RESULTS: The results were clustered into five groups: studies about variations with respect to guidelines and protocols; studies that analyze nursing practice and that of other health professionals; variations in procedures and nursing care; variations in practice between nurses and physicians; and studies that related variability with characteristics of professionals, units or healthcare centers.
CONCLUSION: The majority of papers found were limited to showing the existence of variability, but few sought variables that predicted it. Future investigations should focus on finding predictors of variability to address unjustified variations that are detected.

Keywords: Physician's practice patterns; nursing; review literature as topic


OBJETIVO: El objetivo de esta revisión de la literatura es examinar qué se ha publicado sobre variabilidad de la práctica clínica desde el enfoque de la enfermería.
MÉTODOS: Se realizó una búsqueda bibliográfica en las principales bases de datos internacionales seleccionando aquellos trabajos más relevantes.
RESULTADOS: Los resultados se han agrupado en 5 grupos: estudios sobre variaciones respecto a guías y protocolos, estudios que analizan práctica enfermera y de otros profesionales sanitarios, variaciones en procedimientos y cuidados de enfermería, variaciones en la práctica entre enfermeras y médicos y estudios que relacionan la variabilidad con características de profesionales, unidades o centros sanitarios.
CONCLUSIÓN: La mayoría de los trabajos encontrados se han limitado a mostrar la existencia de variabilidad pero pocos han buscado variables que predigan ésta. Futuras investigaciones deberían centrarse en la búsqueda de variables predictivas de la variabilidad para hacer frente a las variaciones injustificadas que se detecten.

Descriptores: Pautas en la práctica de los médicos; Enfermería; Literatura de revisión como asunto




Evidence-based medicine (EBM) made its appearance in the eighties and can be defined as the conscious, explicit and judicious use of the best scientific evidence available to make clinical decisions about patient care by integrating individual clinical expertise with the best available external clinical evidence from systematic research and with the consideration of patient preferences (1). This approach pursues a clinical practice based on evidence generated by research (2). EBM came about, among other things, as an attempt to standardize clinical practice. The existence of evidence and its diffusion and implementation should, in principle, reduce variability in clinical practice. Although there are earlier precedents (3), it was in the early 1980s when variations in clinical practice (VCP) started to be intensively studied (4,5), with studies on variations in the rates of different surgical procedures between neighboring geographic areas. The phenomenon of variations can be observed from the perspective of different groupings. At a population level, systematic variations in the cumulative incidence of a particular clinical procedure or hospital admission compared to the total population of the area can be observed. These rates allow different areas to be compared and to assess whether there is a different use of services, which could have implications for the costs and outcomes of health care. These studies tend to be carried out between neighboring geographic areas with very similar populations and environmental conditions. In these cases, it would be neither the patients' characteristics nor the environment that would explain the variability.

On an individual level, we can evaluate changes in the care provided to patients in similar clinical situations. Such evaluation not only provides information about the effectiveness or efficiency of technologies, facilities or health professionals but also about how the characteristics of patients (gender, ethnicity, socioeconomic status), health professionals (specialty, age, sex, education, experience, pay), the hospital (size, public or private, rural or urban, university or otherwise) or the healthcare system (financing, organization, coverage) affect variability (6,7). Most articles on variability have focused on the medical discipline, while far fewer studies have been published in the field of nursing.

The aim of this paper is to review the literature, i.e., the original articles, related to the variability of clinical practice in the area of nursing.



In this study, an integrative descriptive review of the original papers related to the variability of clinical practice in the area of nursing was performed.

The study included original papers, published from January 2000 to August 2010, in which determining the variability of clinical practice or describing current nursing practice were among the objectives. Articles specifically dealing with midwives and articles whose objective was to explore attitudes and beliefs about nursing practices or care were excluded from the study. The articles were not excluded on the basis of their methodological quality.

In January 2011, a literature search was performed using the PubMed international databases (digital files on the biomedical and health sciences of the "U.S. National Institutes of Health"), CINAHL (Cumulative Index to Nursing and Allied Health Literature), Cochrane Library, ISI web of Knowledge (Science Citation Index and Social Science Citation Index) and LILACS (Latin American and Caribbean Health Sciences Literature, BVS), limiting the search to between January 2000 and August 2010. The largest descriptor in the Medical Subject Headings (MeSH) of PubMed, on clinical practice variability, in English, was "physician's practice patterns." According to the DeCS database (, in Spanish, it was "pautas en la práctica de los médicos" and in Portuguese, "condutas na Prática dos Médicos". In CINAHL, the descriptor was, in English, "practice patterns". In addition to performing the search according to these terms, the minor MeSH descriptors "clinical practice variation" and "nursing" were used. The searches were conducted using descriptors and also considering these terms as words that might appear in the title or the abstract.

To group the articles thematically, a content analysis was performed (8) considering the aim of the study, the selected population and sample, the methodology used and the main results.



A total of 489 articles were found in the different databases. Of these, 18 were repeated, 413 were excluded after reading their abstracts and 20 after reading the full text. Finally, 38 articles were included in the study.

The progressive reading of the articles, according to inductive categories, allowed us to group them into five major categories: 1) studies on variations in clinical practice regarding guidelines and protocols; 2) studies analyzing variations in the clinical practice of nursing and of other health professions; 3) changes in nursing procedures and care; 4) variations in clinical practice between nurses and physicians; and 5) studies linking variability with professional, unit or health center characteristics. The results from the first four categories are shown in the tables, while the results from the fifth category are laid out in the text. Table 2 shows the three articles whose objective, in addition to showing the current clinical practice of nurses, is to determine the concordance of clinical practice with available guidelines, protocols or evidence. These studies show, for example, variability in wound healing and medication administration.


Tabla 1


The variations in the clinical practice of nursing professionals have been occasionally observed together with the variations in clinical practice of other health professionals. The eight papers shown in Table 3 are intended to describe the clinical practice for specific patient groups among the different professionals who care for them.

Table 4 shows eight studies that describe changes in various nursing procedures and care. Among them are papers describing variations in the prescribing patterns or administration of medications, in health promoting activities or in the specific care practices of intensive care units.

The nine articles in Table 5 examine the variations between nurses and physicians in various activities with the aim of comparing the clinical practice among these professionals. These articles address variations in areas including the prescribing patterns, the care provided and health promotion.

As for the results of the fifth group, we found ten articles linking variability with the characteristics of professionals, patients or units and centers, and also articles searching for predictor variables of variability. Variability was observed in 28 neonatal intensive care units (ICU) regarding the selection of the type of feeding tube, which depended on whether the ICU was located in pediatric institutions (9). Variations were observed in 23 ICUs regarding the neurological assessment of sedated patients, with differences depending on whether the units treated exclusively neurological patients (10). Another study found variations in the activities of nurses by specialty, years of experience and size of the organization. (11) Differences were observed in the prescription and types of prescribed diseases according to educational level, place of work and years of experience. (12,13)

One study found no significant differences among the 256 units surveyed regarding the fluids in which oxytocin was diluted to induce labor (14). A low use of rating scales and a lack of protocols were observed for the treatment of delirium in intensive care units. It was also found that this variability was not explained by the type of hospital. (15) In another study, after surveying 743 nurses on the type of gloves used during wound healing, differences were observed according to whether they worked in acute care centers or in home care.

Variations have been found in the physical activity advice provided by 606 nurses. Providing advice was related to their acknowledging they had sufficient knowledge to do so, their postgraduate training and their exercising (16). One author found variability in the rates of physical restraints within and among 40 acute hospitals. Resources did not explain the variability, but patient and unit characteristics were related to variations in the rate of physical restraints, which was higher in male patients, in patients with mechanical ventilation and in patients admitted to the ICU (17-18).



Most of the reviewed studies were conducted in Anglo-Saxon countries and focused on the variability of clinical practice in the care of adult patients.

The studies are very heterogeneous in terms of procedure and study population; there are different techniques of data collection and analysis, making it difficult to standardize the results of this study. In the reviewed articles, variability has been observed from the perspective of different groupings. Variability has been mainly observed at an individual level and among different professional groups, but it has also been observed among units, centers and even countries.

The methodology used for data collection has been mainly questionnaire surveys. Questionnaires were sent mostly by mail but also via the Internet. Telephone surveys and other methods such as the direct observation and review of medical records were also used.

The studies on the variability in clinical practice began with the medical approach. The production of studies on the variability in medical practice is far greater than the number of studies on the variability in clinical practice from the point of view of other healthcare professionals (20). According to our review, few studies have focused on the variations in clinical practice in the nursing discipline. These articles are indexed in the databases with the descriptor "clinical practice variation", but it seems that many other articles related to this topic are indexed under other less specific descriptors of variability in clinical practice, such as "Questionnaires" or "Health Knowledge", "Attitudes" and "Practice". This indexing has made it difficult to perform a specific bibliographic search. Furthermore, from a population standpoint, there is a lack of population databases containing relevant clinical data, such as functional status or quality of life, to be used in the study of variation. This lack makes it difficult to obtain nursing practice rates, as it is difficult to separate the performance of nurses from the performance of other professionals(21,22). As shown in Table 2, many studies have focused on knowing what nurses do and the concordance with available practice guidelines, protocols or evidence. Such studies are necessary because they serve as a starting point for identifying the areas where there is variability among nurses. Having identified these areas, the next step would be to find out if the variations are justified or unjustified. Justified variations would be ones that occur because of differences in health systems, differences in population characteristics or different patient or professional preferences when more than one option can be scientifically accepted (23,24). These variations are a reflection, in part, of the patient's freedom of choice and the freedom of practice of health professionals, and their elimination makes no sense. Unjustified variations would be ones appearing when all the above-cited factors have already been controlled and that bring no benefits, are detrimental for the patients and lead to a poor quality of health care (25).

The variables that have been associated in these studies with nursing variability are nurse characteristics (e.g., experience, workplace training, degree of knowledge), unit characteristics (e.g., type of patients seen, level of care), hospital characteristics (e.g., size, university teaching, location, country) and patient characteristics (e.g., severity, dependency degree). These variables are consistent with the factors that have traditionally been associated with the variability of practice in medical studies, such as the population-dependent factors, the health system-dependent factors and the clinician-dependent factors. Population-dependent factors relate to differences in the characteristics of the population and the differences in the prevalence of the studied situation, in the distribution of risk factors, the diagnosis, the severity of the disease, the demographic or socioeconomic structure and the educational characteristics of the population that could explain the variability in their care. The health system-dependent factors relate to the human, technical and financial resources, the funding system, coverage, accessibility, economic incentives to professionals, the educational function of the center, the introduction of new technologies, the organizational deficiencies and the lack of equipment, units or personnel. The clinician-dependent factors refer to demographics, training and the professional characteristics involved in the different types of practice (20).

The most cited explanatory theories of variations, so far coming from the medical approach, are the uncertainty hypothesis (26), the patient practice style hypothesis (27) and the physician enthusiasm hypothesis (28). These theories give different values to the factors involved in variability, such as population-dependent factors and supply-dependent factors, which include health system factors and clinician-dependent factors (7).

The uncertainty hypothesis has had the greatest impact. It is based on differences in the clinical evaluation of the patient or different beliefs about the value of the procedures, the origin of these differences being the presence of uncertainty (no scientific evidence on the outcomes of alternative procedures in a specific situation exists) or ignorance (scientific evidence on the value of the procedures exists, but the health professional is unaware or despite being aware, decides to employ other guidelines).

Although uncertainty in the field of decision-making by nurses has indeed been studied (29,30), and although the variables associated with nurse variability match the factors associated with medical variability, no studies have been found on explanatory theories of practice variability in nurses, and only one study tries to position the variations in nursing practice within the explanatory theories of variation (31).



Variations in clinical practice have been poorly studied in nursing. The majority of the articles found were limited to showing the existence of such variability. In contrast, few have sought variables related to it, and studies considering the variability in terms of variables at different levels (e.g., personal, unit, center, region) are practically inexistent. Future research should focus on finding predictors of variability to address the unjustified variations that are detected. The use of a common taxonomy and the standardization of health care through protocols and clinical practice guidelines are emerging as a way to reduce variations in clinical practice.



The authors wish to thank Marília Valim Duarte, a doctoral student at the University of São Paulo, Ribeirão Preto School of Nursing, Brazil, for her collaboration in the final review of the work and the translation of the abstract of the article.



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Corresponding Author:
José Fernández de Maya
Calle Tonico Sansano nº 14
CP 03293. Elche (Alicante)

Received article 20/09/2011 and accepted 19/07/2012

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