Practice Development: A Managers Agenda

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Practice Development A Managers Agenda

• Brendan McCormack,
• Professor of Nursing Research, University of
  Ulster
• Visiting Professor of Nursing, Prince of Wales
  Hospital
• Adjunct Professor of Nursing, Monash University,
  Melbourne, Australia
• Visiting Professor, University of Northumbria,
  Newcastle, England

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The Context of Practice McCormack et al
(2002) getting evidence into practice the
meaning of context, Journal of Advanced Nursing,
38(1), 94-104
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Characteristics of a Strong Context (McCormack
et al 2002)

• Appropriate transparent decision-making.
• Boundaries clearly defined.
• Power authority defined.
• Adequate resources.
• Appropriate information feedback systems.
• Receptive to change.
• Individual staff and clients are valued.
• Promotes learning in and from practice.
• Transformational leadership.
• Individual and performance feedback/evaluation

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Understanding the Importance of Context

• Strong contexts have a positive impact on patient
  outcome e.g. Aiken et al, 2002
• Higher reported levels of emotional exhaustion
  associated with poor context Estabrooks et al,
  2007
• Nurses working in better contexts report
  significantly more research utilization, more
  staff development, and lower rates of patient and
  staff adverse events than those in less positive
  contexts Cummings et al, 2007
• Positive relationships in teams impact positively
  on staff development opportunities, research use
  and autonomy over decision-making Slater
  McCormack, in press

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PD History

• Oxford, England 1980s
• PD Hospital Roles 1990/2000s
• PD methods and Conceptual Frameworks
  2000/present
• International Developments
• PD Books (McCormack, Manley Garbett 2004
  Manley, McCormack Wilson, in press)
• Three types of PD Technical, Emancipatory and
  Transformational

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• Practice Development that is focused on Technical
  Change
• (Manley McCormack, 2004)

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Technical PD

• CHARACTERISTICS
• Narrow view of PD
• Focuses only on technical skill technical
  knowledge
• getting research into practice
• Providing appropriate information training

• ASSUMPTIONS
• Knowledge, skills benchmarks are appropriate
  for all contexts
• Best practice is universally defined
• Knowing the evidence will ensure action
• Emphasis is on outcomes

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Where do the ideas for action come from?

• Topdown/managerially driven
• Ideas for action defined by or come from
  management
• Policy driven

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OUTCOME EVALUATION

• Intervention-linked, e.g.
• cost-effectiveness,
• user satisfaction
• technical indicators

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• Practice Development that is focused on
  Developing the culture and context of Practice
  (Emancipatory PD)
• (Manley McCormack, 2004)

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Definition of Emancipatory PD

• Practice development is 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
  and continuous processes of emancipatory change
  that reflect the perspectives of service users
  and service providers
• (Garbett McCormack 2002 2004)

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transforming individuals and contexts of care
Improving patient person/ centred care
Learning in and from practice
Systematic approaches
Values and beliefs
(Garbett McCormack 2002/04)
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PD - Changing Culture and Context

• CHARACTERISTICS
• Broad view of PD
• Focuses on both getting research into practice
  and creating a culture of innovation
  effectiveness
• helping practitioners break down barriers to
  action

• ASSUMPTIONS
• Best practice is locally defined and contextual
• Research will not be used unless it is owned
  perceived as relevant
• Emphasis is on processes as well as outcomes

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Where do the ideas for action come from?

• Practice driven
• Ideas for action arise from collective group
  processes
• Policy use

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OUTCOME EVALUATION

• Intervention-linked e.g.
• cost-effectiveness
• user satisfaction
• technical indicators
• Process outcomes
• Individual/group enlightenment, empowerment,
• Cultural change
• Stakeholder Analysis linked

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Transformational Practice Development

• (McCormack Titchen, 2006
• Titchen McCormack, in press)

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• Practice development is a continuous process of
  developing person-centred cultures. It is enabled
  by facilitators who work with teams to blend
  personal qualities and creative imagination with
  practice skills, practice wisdom and an evolving
  authentic self. Learning through engagement with
  body, heart, mind and soul brings about
  transformations of self and work practices. This
  is sustained by embedding both processes and
  outcomes in corporate strategy.
• (McCormack, Manley Wilson, in press)

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Human Flourishing

• Focuses on maximising the potential for
  individuals to achieve their potential for growth
  and development
• Thus human flourishing is seen as both the end
  and the means of practice, practice development
  and practitioner research

(adapted from McCormack Titchen, 2006)
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• the transformation of practice understands
  that changing practices is not just a matter of
  changing the ideas of individual practitioners
  alone, but also discovering, analysing and
  transforming the social, cultural, discursive and
  material conditions under which their practice
  occurs (Kemmis, 2005)

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Person-centred care is achieved through

• Developing person-centred care systems
• Developing person-centred cultures
• Developing practitioners to
• work collectively towards a person-centred
  approach
• learn in and from practice
• use evidence in and from practice including the
  patients' experience
• systematically evaluate practice change and
  innovation
• Release their creativity to address issues in the
  workplace

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A realist synthesis of Evidence Relating to
Practice Development

• A study for NHS Education NHS Quality
  Improvement Scotland http////www.nhshealthqualit
  y.org/nhsqis/qis
• Professor Brendan McCormack University of
  Ulster/Royal Hospitals Trust, Belfast
• Belinda Dewar - Queen Margaret University
  College, Edinburgh
• Jayne Wright, Research Associate, University of
  Ulster
• Dr Gill Harvey Manchester Business School,
  University of Manchester
• Robert Garbett University of Ulster/Royal
  Hospitals Trust, Belfast

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multidisciplinary versus unidisciplinary practice
developments.
service user involvement (or engagement) in PD
work.
The involvement of managers in PD is crucial to
the successful implementation of PD processes and
the sustainability of outcomes. Managers need to
understand how PD can contribute to the
modernisation and development of effective
services.
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Practice developers in formal PD roles continue
to experience isolation and role ambiguity. There
is a need to develop a greater understanding of
the particular knowledge, skills and expertise
needed to operate in differing PD roles.
Collaborative relationships with HEIs
The contribution of traditional education
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There is growing consensus concerning the
practice development methods that are effective
in ensuring participatory engagement and in
bringing about changes in the culture and context
of practice.

• Methods that increase use of and generate
  knowledge.
• Methods that involve stakeholders
• Methods that increase participation and shared
  ownership.
• Methods that lead to improved patient experience
  and care

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Need to develop PD costing models
A wide range of outcomes are evident from
published practice developments and there is a
need for the replication of these in further
studies.
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Outcomes from PD

• 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 framework
  integrated care pathway)

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Issues for Managers

• Technical, emancipatory or transformational PD?
• Shared values and vision.
• Facilitators and availability of facilitation
  expertise.
• Making inspirational and transformational
  leadership available.
• Links/relationships with HE?
• The role of the nurse manager as a stakeholder in
  PD.
• The reality of empowerment.
• Political and strategic awareness and engagement.
• Resource availability.
• Supporting PD methods in workplaces
• Making collaborative, participatory and inclusive
  management/leadership a reality.
• Outcome expectations and linking with
  strategy/policy directions.
• Supporting enabling learning cultures.

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Why Bother?
Practice Development gave us the permission or
license to do what we had always wanted to do.

• PD does what it is often hard to do in large
  organisations and in large systems
• it works with individuals and teams
• it helps engage individuals with the larger
  vision, a shared vision
• it helps to create links with their own
  aspirations
• it has the potential to translate complex
  organisational and strategic agendas into
  practice reality
• PD by working in respectful ways can help move
  health care staff and patients to a better
  alignment of what constitutes person centred
  care.
• it moves the energy that would otherwise have
  been expended in conflictual agendas and
  resistance towards shared agendas.
• it facilitates the system as a whole to re-engage
  with the untapped potential lying within the
  healthcare workforce and their patients.

(McCormack, Manley Walsh, in press)