Re-mapping client journeys and professional identities: a review of the literature on clinical pathways.

OBJECTIVES To explore the growing use of clinical pathways by nurses and midwives, their impact on client care, and the potential consequences of widespread pathway utilisation for the professional identity and knowledge base of nursing and midwifery. METHODS A keyword search was performed within CINAHL and PubMed for the period 1995-2006 to identify relevant material, and article bibliographies were examined to identify relevance references. Thirty-nine publications were selected for inclusion in the analysis on the basis that they offered the most original account of the development of pathways or their effectiveness, or because they provided useful theoretical concepts. A thematic analysis of the selected articles was undertaken. RESULTS The review identified four main themes: the multiple aims of clinical pathways; the process of initial development; pathway implementation in practice, and the impacts of pathways on client care, professional identities, and the nature of written documentation. Clinical pathways have multiple aims, including standardising practice, levering external evidence into local health care work, and improving interprofessional co-ordination. The review found limited evidence of pathways' impact on client care, but the existing research suggests that they may be most suitable for predictable, routinised surgical procedures. Key concepts, such as variance and audit were found to be poorly defined. Clinical pathways appear to achieve many of their effects at the development stage and the reshaping of professional interactions. CONCLUSIONS Given their widespread adoption and valorisation as tools of evidence-based practice, the dearth of evidence for clinical pathways should raise concerns. Clinical pathways may have significant impacts on nursing and midwifery as professions, both through redrawing professional identities and boundaries, and transforming the ways in which nurses and midwives document care. The impact of standardised pathways on professional ideologies which emphasise individualised care, and clinical autonomy will require long-term programmes of research.