International Practice Development in Nursing and Healthcare

Kim Manley, Brendan McCormack, Valerie J. Wilson, Kim Manley, Brendan McCormack, Valerie Wilson

• Publisher: Wiley-Blackwell
• Year: 2013
• ISBN:
  9781118693469
• Edition: 1
• Topic: Medicine
• Subtopic: Nursing Skills

International Practice Development in Nursing builds on Practice Development in Nursing, edited by the same editors and is the first book to develop a truly international practice development perspective.

Practice development is a key concept in developing effective nursing care which is firmly embedded in health service modernisation agendas, clinical governance strategies, team and cultural developments and in quality improvements that directly impact on patient care in the UK and internationally. Practice development acknowledges the interplay between the development of knowledge and skills, enablement strategies, facilitation and a systematic, rigorous and continuous processes of emancipatory change in order to achieve evidence-based, person-centred care.

International Practice Development in Nursing is an essential resource for all practice developers and for nurses with a remit for facilitating innovation and change in practice.

1

Introduction

Kim Manley, Brendan McCormack and Val Wilson

Introduction

For more than 20 years, practice development (PD) has been used as a term to describe a variety of methods for developing healthcare practice. In particular, the term has been used in the context of nursing development. Over the past 10 years significant conceptual, theoretical and methodological advances have been made in the development of frameworks to guide PD activities. Of most significance has been our increased understanding of key concepts underpinning PD work irrespective of the methodological perspective being adopted – for example, workplace culture (Manley, 2004), person centredness (McCormack, 2004; Dewing, 2004; Titchen, 2000; Nolan et al., 2004), practice context (McCormack et al., 2002), evidence (Rycroft-Malone et al., 2003), evidence implementation (Rycroft-Malone, 2004), values (Manley, 2001; Wilson et al., 2005; Wilson, 2005) and approaches to learning for sustainable practice (Dewar et al., 2003; Wilson et al., 2005; Wilson et al., 2006; Hardy et al., 2006). A number of researchers have explored the meaning of PD through conceptual analysis (Garbett & McCormack, 2002, 2004; Unsworth, 2000), action inquiry (Binnie & Titchen, 1999; Manley, 1997; Clarke et al., 2004; Clarke & Wilcockson, 2001; Gerrish, 2001) and evaluation (McCormack et al., 2004; Wilson & McCormack, 2006; Tolson, 1999).

In a concept analysis of PD, Garbett and McCormack (2004) articulated the interconnected and synergistic relationships between the development of knowledge and skills, enablement strategies, facilitation and systematic, rigorous and continuous processes of emancipatory change in order to achieve the ultimate purpose of evidence-based person-centred care. Manley and McCormack (2004) articulated these elements of PD in a model called ‘emancipatory PD’, drawing on previous theoretical developments in action research (Grundy, 1982). Emancipatory PD explicitly uses critical social scientific concepts on the basis that the emphasis on the development of individual practitioners, cultures and contexts within which they work, will result in sustainable change. Whilst one of the key distinctions between action research and emancipatory PD has been the explicit intent of developing transferable knowledge in action research, this increased PD literature also articulates transferable principles for action and thus demonstrates the ‘coming of age’ of PD and its potential as a systematic process of transformative action. In a recent systematic review of the evidence underpinning PD, McCormack et al. (2007a) identified a range of outcomes that have been achieved from systematic PD work, including the following:

• Implementation of patient care knowledge utilisation projects.
• Development of research knowledge and skills of participating staff.
• Development of facilitation skills among staff.
• Development of new services.
• Increased effectiveness of existing services or expansion of more effective services.
• Changing workplace cultures to ones that are more person centred.
• Developing learning cultures.
• Increased empowerment of staff.
• Role clarity and shared understanding of role contributions.
• Development of greater team capacity.
• Development of frameworks to guide ongoing development (e.g. competency frameworks, integrated care pathways).

Whilst these outcomes are evident in the published literature, it is also evident that much work is needed to develop strategic level evaluation frameworks that reflect the complex and multi-faceted nature of PD interventions.

International collaborations are emerging that will enable these advances to happen. Take for example this book; each chapter has a number of authors who are drawn from across the world with differing workplace contexts and cultures, with a multiplicity of professional roles from a diverse range of clinical and academic backgrounds. This of itself has been a major achievement in crossing international boundaries with PD. The issue of language is of course at times confusing across international boundaries; to ensure consistency throughout this text we have used the universal term practitioner, which in the Australia and New Zealand context denotes a clinician.

To date a number of collaboration endeavours have developed across different contexts, providing wider and more sophisticated understandings of PD to be developed. An example of this work can be drawn from the International Practice Development Colloquium (IPDC), a group of practice developers from the United Kingdom, The Netherlands New Zealand, and Australia that meet and work together to develop PD, theory and practice. The IPDC have established a number of focus areas in which they wish to advance PD. Three of these groups have contributed to work within this book (Chapters 4, 7 and 8). Each of these chapters is a collaborative endeavour to unpick, understand and advance our thinking about PD.

Collaborative research links have also been established to provide a platform for systematic studies that not only evaluate complex interventions, but also do so across borders and contexts. An example of this work is a project titled ‘The development of person-centred cultures through an integrated practice development and work-based learning program’. This project takes place in number of clinical units in four area health services across two countries (UK and Australia) and involves a partnership with two universities. Interventions are multi-faceted and are developed within particular contexts. Data are collected and analysed within each area health service and cross-comparisons will take place between these sites. The project is layered in such a way as to establish a range of outcomes for patients, staff, units and organisations in each context (area health service) as well as to develop outcomes for the overall project. Through a strategic evaluation framework the investigators hope to make explicit the transformations that are occurring for individuals (patients, families and staff), teams, and organisations as a result of PD interventions.

The conceptual, theoretical and methodological advances that are being operationalised through national and international collaborations are reflected throughout this book, demonstrating advancements in PD since the first volume of work presented in Practice Development in Nursing (2004, edited by McCormack, Manley & Garbett). Since 2004 these advances have contributed to the development of a PD knowledge base and helped in articulating the key principles underpinning PD.

Practice development principles

With this increasing advancement in our understanding of PD come both increasing complexity with regard to the theoretical ideas surrounding it, and at the same time increasing clarity about how these theoretical ideas inform PD activity as a specific approach in the workplace. This paradox leads to the need for a set of principles that articulate the practical activity involved in PD in a way that also integrates the theoretical and philosophical ideas that are emerging.

Nine key principles are proposed as identifying the primary elements of PD activity. They are particularly intended to help other stakeholders (in particular commissioners, research funders, policy makers) to be clear about what PD is and what it is not. These principles provide the criteria or standards by which any activity presented as PD could be judged as such and differentiated from any other activity that may be similar or different. Similarities and differences with, for example, service development are cogently illustrated in Chapter 16, where PD is articulated as an approach that focuses on changing people and practice rather than just systems and processes, although both are integrated as illustrated in Chapter 3.

Whilst there are demonstrable outcomes from PD as illustrated above, there is an urgent need for articulating the outcomes of PD in a way that

• matches current and future healthcare needs in the context of global healthcare trends that will become the future driver for policy makers and healthcare commissioners, and
• is recognised by policymakers and commissioners as an approach that is worth investing in because it can assist with addressing the above in a sustainable way.

The outcomes of PD therefore need to be constructed in messages that important stakeholders can not only recognise but also need to be linked to a specific set of principles that encompass and guide the methods and activity used.

Nine PD principles are identified that inform all PD activity, themed in relation to the following:

• Purpose
• Level
• Learning
• Evidence use and evidence development
• Creativity
• Methodology and methods

The principles (Box 1.1) are described overleaf, and whilst every principle may be reflected implicitly in each chapter, those chapters that illustrate the principles most clearly are identified.

Purpose

Principle 1. PD aims to achieve person-centred and evidence-based care that is manifested through human-flourishing and a workplace culture of effectiveness in all healthcare settings and situations.

The aim of PD is to develop effective workplace cultures that have embedded within them person-centred processes, systems and ways of working. Chapter 2 of this book explores person-centred systems and processes and the impact these hold for care delivery as well as for patients, families and staff. Person-centred processes take into account the individual’s cultural perspective as well as the prevailing workplace culture that exists and the impact this may hold for people experiencing this culture. The relevance of this for PD is explored in detail in Chapter 9, which takes us on a cultural journey through the authors’ engagement with the broader cultural context of living and working within New Zealand. This chapter helps the reader explore the importance of being culturally sensitive in PD work.

A manifestation of effective workplace cultures is the use of evidence to inform decision-making and the development of practice in context. Within PD evidence this includes a broader scope than is often found within the evidence-based care movement and is sourced from four key areas: research; clinical experience; patients, clients and carers; and local context and environment (Rycroft-Malone et al., 2004). A broader discussion of evidence and its relevance to decision-making is captured in Chapter 5 of this book.

Understanding the relationship between the delivery of person-centred care and the resultant outcomes is an integral component of PD work. We are interested not only in the outcomes for patients, families and staff, but also the impact that personcentred care has on the evolving workplace culture. Chapters 10 and 11 explore through evaluations of PD initiatives the relationship between PD, person-centred practice, changes in workplace culture and the potential for human-flourishing to occur. It is through this type of exploration that we can hope to understand more fully the potential we have in achieving the stated purpose of PD.

Box 1.1 Principles of practice development

Principles Practice development	Focus	Chapter(s)
1. It aims to achieve person-centred and evidence-based care that is manifested through human-flourishing and a workplace culture of effectiveness in all healthcare settings and situations.	Purpose	2, 5, 9, 10, 11
2. It directs its attention at the micro-systems level – the level at which most healthcare is experienced and provided, but requires coherent support from interrelated mezzo- and macro-systems levels.	Level	2, 3, 16
3. It integrates work-based learning with its focus on active learning and formal systems for enabling learning in the workplace to transform care.	Learning	6, 14
4. It integrates and enables both the development of evidence from practice and the use of evidence in practice.	Evidence use and development	5, 15
5. It integrates creativity with cognition in order to blend mind, heart and soul energies, enabling practitioners to free their thinking and allow opportunities for human-flourishing to emerge.	Creativity	4
6. It is a complex methodology that can be used across healthcare teams and interfaces to involve all internal and external stakeholders.	Methodology and methods	2, 17
7. It uses key methods that are utilised according to the methodological principles being operationalised and the contextual characteristics of the PD programme of work.		All
8. It is associated with a set of processes including skilled facilitation that can be translated into a specific skill-set required as near to the interface of care as possible.		8, 12, 13
9. It integrates evaluation approaches that are always inclusive, participative and collaborative.		7

Level

Principle 2. PD directs its attention at the micro-systems level – the level at which most healthcare is experienced and provided, but requires coherent support from interrelated mezzo- and macro-systems levels.

From its inception PD has long been recognised as needing to dovetail with supportive and enabling organisational frameworks for its potential to be fulfilled (McCormack et al., 1999). Subsequently, the importance of executive sign up and support has been recognised as essential for PD to achieve success (Manley & Webster, 2006). Whilst other approaches to developing quality services may emphasise organisational approaches to achieving change and innovation, the primary focus of PD is at the level of healthcare practice. This level (the ‘micro-systems level’) is where healthcare services most closely interact with patients and users through practitioners, practice teams and patient pathways. There are a number of assumptions that drive this specific focus in PD:

• Staff providing care and services to patients and users are most likely to be able to recognise the barriers to change, where improvements can be made and the innovations that can be introduced when supported to do so.
• It is at this level that care is experienced by users and therefore positive change has most potential for impacting on the user’s experience and outcome.
• Involving, supporting and enabling practitioners and practice teams with users to lead change will more likely achieve internalised and embedded change that is self-sustaining.
• Developing practitioners to think and work in a person-centred and evidence-based way will help them to work more smartly as well as be self-sustaining and self-sufficient in their own problem-solving and learning for the future.

PD is an approach that can help practitioners to work with patients, users and colleagues in a person-centred way regardless of the issue or topic that may be in vogue at any one time. These ideas are further developed in Chapter 2, where the contribution of PD to developing person-centred systems that achieve integration and continuity of care for patients and users through structures, processes and patterns, manifested in behaviour, are explored in depth. Whilst the development of person-centred systems at the micro-systems level is the focus of PD, the need for cultures of effectiveness at every level of the organisation is recognised through the integration necessary between micro-, mezzo- and macro-systems levels. The success of micro-systems rely on organisational systems that actively support practitioners and practice teams to deliver on organisational values; something that is seen very effectively in the Magnet Hospital Programme and subsequently demonstrated through its outcomes (Aiken et al., 2002) (see Chapter 17).

Learning

Principle 3. PD integrates work-based learning with its focus on active learning and formal systems for enabling learning in the workplace to transform care.

Learning in and from practice is a major component of PD identified in the original concept analysis work (Garbett & McCormack, 2004). Since then our understanding has continued to grow about how work-based learning approaches enable the transformation of individuals, teams and practice within workplaces (Dewar & Sharp, 2006; Wilson et al., 2006; Hardy et al., 2006). The role of skilled facilitation and formal systems for enabling learning as well as its assessment, implementation and evaluation in the workplace are gaining increasing recognition as being instrumental, together with a genuine learning culture and other factors, in developing and maintaining individual, team and organisational effectiveness (Manley et al., 2007).

Work-based learning is integral to PD. Learning in PD arises from developing self knowledge and awareness through structured and intentional reflection about the impact of our actions or inactions on others within the context of our workplace. Learning in PD is not only fostered through specific processes but also through the implementation of systems such as mechanisms for clinical supervision that sustain and transform it in the workplace (Hardy et al., 2006). Processes include critical analysis and reflection, which act as motivators for action, enabling practitioners to continue to be self-sufficient in their learning approaches for life. The range of approaches used to support learning in PD, termed active learning, are presented in Chapter 6. Active learning is a new but broader concept for approaches to learning that build on the formal approaches usually associated with PD such as action learning and clinical supervision. ...