Practice Development in Nursing and Healthcare

Brendan McCormack, Kim Manley, Angie Titchen, Brendan McCormack, Kim Manley, Angie Titchen

• Publisher: Wiley-Blackwell
• Year: 2013
• Print ISBN: 9780470673119
• eBook ISBN: 9781118448786
• Edition: 2
• Topic: Medicine
• Subtopic: Nursing Skills

In its first edition, Practice Development in Nursing made an important contribution to understanding practice development and its core components. Now fully updated to take into account the many developments in the field, the second edition continues to fill an important gap in the market for an accessible, practical text on what remains a key issue for all members of the healthcare team globally.

Practice Development in Nursing and Healthcare explores the basis of practice development and its aims, implementation and impact on healthcare, to enable readers to be confident in their approaches to practice development. It is aimed at healthcare professionals in a variety of roles (for example clinical practice, education, research and quality improvement) and students, as well as those with a primary practice development role, in order to enable them to effectively and knowledgeably develop practice and the practice of others.

Key features:

• New updated edition of a seminal text in the field, including significant new material
• Relevance to the entire healthcare team
• Accessible and practical in style, with case studies, scenarios and examples throughout
• Edited by and with contributions from experts in the field
• Fully updated to include the latest research
• Supported by a strong evidence base

1

Introduction

Brendan McCormack1, Kim Manley2 and Angie Titchen3

1University of Ulster, Newtownabbey, UK
2Canterbury Christ Church University, Canterbury, UK
3Fontys University of Applied Sciences, Eindhoven, The Netherlands

WHY DEVELOP PRACTICE

Internationally, for the past 15 years, health care has been dominated by an agenda of reformation, modernisation and transformation. During this time, there has been a significant emphasis on person-centred care delivery in a strategic and political context that has been focused on cost containment and cost reduction. For many commentators this is indeed a paradox and one that is not ‘healthy’ in a health economy (Bechtel & Ness, 2010; Braithwaite, 2010). However, the challenges of delivering person-centred health care are not solely about economic resources, but are as much about the focus of staff and their priorities. Changing the model of care from one that is primarily hospital based, to one that is delivered as a partnership between service users, all care settings and public and private providers has resulted in major changes to the way care services are delivered and operationalised. These changes have been key features of the transformation agenda. Roles have needed to change among all professions, and professional boundaries have been increasingly blurred.

However, whilst there has been an emphasis in policy and strategy documents on the development of person-centred services, this has merely been, at worse, rhetoric, or at best, a simplistic idea based on providing service users and their families with more choices about how their health care is delivered. This view is reinforced by a continuous and sustained focus among patient advocacy groups and media commentators on the poor quality of care in hospitals, the poor treatment of vulnerable patients and a lack of respect and dignity in individual care practices (see, e.g., the UK Patients Association ‘Care Campaign’, http://patients-association.com/Default.aspx?tabid=237, and the recent ‘I’ newspaper series on poor nursing, http://www.independent.co.uk/life-style/health-and-families/features/nurses-do-not-wake-up-each-morning-intent-on-delivering-poor-care-7644061.html?origin=internalSearch). Most recently in the United Kingdom, a commission of inquiry into dignity in hospitals and nursing homes has been instigated by three major organisations – AgeUK, The Local Government Association and the NHS Confederation (http://www.ageuk.org.uk/home-and-care/improving-dignity-in-care-consultation/). The investigation has focused on understanding the contextual factors that, on the one hand, have resulted in some of the greatest advances in health care, whilst on the other, seem to have eroded the dignity of patient experience – particularly among older people. A key recommendation of the commission is:

Hospitals should introduce facilitated, practice-based development programmes – ‘learning through doing’ – to ensure staff caring for older people are given the confidence, support and skills to do the right thing for their patients.

This recommendation by the Dignity Commission highlights the need for ongoing development of practice in clinical settings and reinforces the views of key commentators that widespread top-down organisational changes without concomitant bottom-up development programmes result in ineffective change processes and poor outcomes (Braithwaite et al., 2006). Indeed, Braithwaite and colleagues suggest that, without programmes of development at the micro level (clinical practice environment), the large-scale and top-down driven change has a negative impact. Drawing on their work that focused on introducing new information technology, they suggested that the imposing of reorganisations, restructuring and attempting to change corporate culture by senior management instigation frequently fell short and had the potential to create major patterns of dissension and resistance (Westbrook et al., 2007).

This evidence from Braithwaite et al. (2006), which confirms what has been known in the change literature for well over 30 years (see Ottaway, 1976; Beer, 1980), was recently reinforced by a personal story of a colleague who had had a recent hospital experience:

I don't think the <hospital name> nurses I encountered were uncaring. They were ill prepared for the tasks they faced, sometimes insensitive, unsupported by the structures and ethos of the service and very overwhelmed, but I wouldn't say they didn't care or that they didn't, for the most part, work hard. They reminded me of the adage ‘the road to hell is paved with good intentions' and even if they had known more about dementia and mania, or at least have been aware of what they didn't know, they still couldn't have functioned adequately within the structures and systems (Personal Communication, 2011)

Since its origins in the late 1970s, practice development has been aware of the pitfalls of top-down change alone, and so it pays attention to these local practices in clinical settings, whilst focusing on the need for a systems-wide focus on person-centredness and the development of person-centred cultures. In particular, practice development pays attention to what are increasingly acknowledged as ‘the human factors’ in health care – factors that focus on the relationship between staff's well-being, leadership, team relationships, morale, satisfaction and a sense of belonging among staff in the context of clinical effectiveness and patient outcome. For example, Maben et al. (2012) have identified that the quality of care for people in acute settings relies on resilience building and renewal for staff, leadership and support and teamwork. They also highlight the importance of adequate staffing. Whilst initiatives such as ‘Transforming Care at the Bedside’ (http://www.ihi.org/offerings/Initiatives/PastStrategicInitiatives/TCAB/Pages/default.aspx) address such contextual issues as these, others have commented that it should not be assumed that human factors in health care can be addressed by the transfer of quick-fix solutions (Cooke, cited in Feinmann, 2011). Whilst these initiatives and innovations do have an important role to play in changing practices and ensuring that systems are responsive to the needs of patients and families, developing evidence-informed and person-centred cultures of effectiveness needs a greater focus on understanding the motivation behind practices and working with these motivations to implement solutions as an integrated part of health care service delivery.

The development of person-centred cultures cannot be achieved through a focus on implementing solutions that address particular aspects of system ineffectiveness. Instead, sustained and integrated approaches to the creation of person-centred cultures systematically address embedded patterns in workplaces. To bring about fundamental change in complex systems requires the recognition of patterns that drive thinking and behaviour (Plsek, 2001). Patterns are often ignored or go unchallenged despite changes to structures and processes (Plsek, 2001). This is because patterns are associated with distinctive behavioural norms that manifest specific values, beliefs and assumptions within a workplace. These aspects together by definition are termed ‘culture’ (Schein, 2004), where implicit importance is placed on how things are done and what counts as important. Patterns describe problems that occur over and over again in an environment or operational context and they describe the core of a solution to that problem in such a way that it can be used an infinite number of times – without ever doing it the same way twice. As such, patterns can be much generalised at a conceptual level whilst they are absolutely unique at a local implementation level.

However, in their most recent work, McCance et al. (2012) have identified that despite what is known about the importance of person-centred care and the need for the development of person-centred cultures, the majority of service users only experience ‘person-centred moments’, that is, moments of time when care is person-centred set within an overarching care experience of routine. McCance et al. (2012) have concluded that person-centredness is a fragile concept and is dependent on a person-centred culture that has consistent care delivery, effective care coordination, good leadership, a knowledgeable and skilled care team, systems-wide support for person-centredness and a flexible model of care delivery. So, this would suggest that even within a stringent economic climate, principles of person-centredness can be maintained and quality systems enhanced if issues such as leadership, facilitation, teamwork and collective vision are held central in service development programmes. All of which are central concerns of practice development.

PRACTICE DEVELOPMENT – ITS ORIGINS

In 2004 Practice Development in Nursing was published (McCormack et al., 2004) and its publication was a political act and landmark in making visible significant work that had previously been undertaken in establishing practice development as a movement in the development of nursing practice. Prior to its publication, practice development had been evolving through a range of projects that had each focused on different approaches to improving patient care in different settings, but which had also focused on articulating the contribution of nurses to effective patient care. The term ‘practice development’ was at that time widely but inconsistently used in British nursing. It was used to address a broad range of educational (McKenna, 1995), research (Rolfe, 1996) and audit (NHSE, 1996) activity. In much of the literature, there was an emphasis on the use of research evidence in practice (e.g. Kitson et al., 1996). Practice development was underdeveloped as a methodology, and whilst there was a lot of enthusiasm for the methods because they resonated with the increased emphasis on quality improvement, clinical audit and using research in practice, there was no coordinated approach, nor indeed common understanding of the most effective methodologies.

In 2002, Garbett and McCormack published the first concept analysis of practice development, and this analysis brought together what had been until then a disparate body of work that used different methods, but all of which had the shared intention of developing patient care and nursing practice. The principles that underpinned this body of work included:

• an emphasis on improving patient care;
• an emphasis on transforming the contexts and cultures in which nursing care took place;
• the importance of employing a systematic approach to effect changes in practice;
• the continuous nature of practice development activity;
• the nature of the facilitation required for change to take place.

(Garbett & McCormack, 2002)

The concept analysis highlighted that there were clear areas of congruity between work being undertaken by practice developers and the kinds of practice being promoted in the national health care policy at that time. For example, the then England's Chief Nursing Officer launched a publication in the wake of the NHS Plan (Mullally, 2001) that emphasised the importance of learning from practice, being responsive to patients and developing adaptability to change. Clearly, these themes resonated with the principles underpinning practice development, and so the importance of the contribution of staff working in the many and varied practice development roles across the United Kingdom were clearly central to the wholesale cultural shift that was being demanded of the NHS. Networks such as ‘The UK Developing Practice Network’ were focused on that agenda and did much to advance understanding of the role of the Practice Development Nurse in the United Kingdom.

The publication of Practice Development in Nursing in 2004 added to a growing body of conceptual, theoretical and methodological advances in the development of frameworks to guide practice development, including workplace culture (Manley, 2004), person-centredness (Binnie & Titchen, 1999; Dewing, 2004; McCormack, 2004; Nolan et al., 2004), practice context (McCormack et al., 2002), evidence (Rycroft-Malone et al., 2004), evidence implementation (Rycroft-Malone et al., 2004), values (Warfield & Manley, 1990; Manley, 2000a, 2000b; Manley, 2004; Wilson, 2005; Wilson et al., 2005) and approaches to learning for sustainable practice (Dewar, 2002; Titchen, 2003; Titchen & McGinley, 2003; Wilson et al., 2005; Hardy et al., 2006; Wilson et al., 2006).

Practice development was defined as:

A continuous process of improvement towards increased effectiveness in patient centred care. This is brought about by enabling health care teams to develop their knowledge and skills and to transform the culture and context of care. It is enabled and supported by facilitators committed to systematic, rigorous continuous processes of emancipatory change that reflect the perspectives of both service users and service providers. (McCormack et al., 2004, 316)

This definition has been widely used internationally in ...

Table of contents

• Cover
• Dedication
• Title Page
• Copyright
• Contributors
• Preface
• Acknowledgements
• Chapter 1: Introduction
• Chapter 2: Learning to be a Practice Developer
• Chapter 3: What Is Practice Development and What Are the Starting Points?
• Chapter 4: Approaches to Practice Development
• Chapter 5: A Case Study of Practice Development ‘The Practice Development Journey’
• Chapter 6: Getting Going with Facilitation Skills in Practice Development
• Chapter 7: How You Might Use PARIHS to Deliver Safe and Effective Care
• Chapter 8: Working Towards a Culture of Effectiveness in the Workplace
• Chapter 9: Evaluation Approaches for Practice Development: Contemporary Perspectives
• Chapter 10: Outcome Evaluation in the Development of Person-Centred Practice
• Chapter 11: Practice Development as Radical Gardening: Enabling Creativity and Innovation
• Chapter 12: Building Capacity for Transformation through Practice Development: Two Case Studies in NHS Trusts, England
• Chapter 13: The Use of Action Hypotheses to Demonstrate Practice Development Strategies in Action
• Chapter 14: The Contextual Web of Practice Development
• Index