Clinical Redesign, Modernisation and Practice Development : A Synergistic Relationship

1
Clinical Redesign, Modernisation and Practice
Development A Synergistic Relationship?

• Brendan McCormack,
• Professor of Nursing Research, University of
  Ulster

2
Healthcare Reform Agencies
3
Modernisation Integration

• horizontal integration - strategies linking
  similar levels of care (e.g. overcoming
  professional and departmental boundaries)
• vertical integration - strategies linking
  different levels of care (e.g. primary,
  secondary, tertiary)
• continuity of care - strategies that highlighting
  the patients experience (e.g. models of care)
• integrated care - a broad term encompassing the
  bringing together of different aspects of
  services (e.g. technological, managerial and
  economic integration).

4
Systems elements structures, processes, patterns
5
Patterns are often ignored or go unchallenged
despite changes to structures and processes
(Plsek 2001 Ill 2005). 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. To bring about fundamental change in
complex systems requires the recognition of
patterns that drive thinking and behaviour (Plsek
2001).
6
Micro-systems

• are small functional, front-line units that
  provide most healthcare to most people. They are
  the essential building blocks of the health
  system. They are the place where patients and
  healthcare staff meet.
• (Dartmouth Hitchcock Medical School)

7

• Ultimately the outcomes of the macro-systems
  can be no better than the micro-systems of which
  it is composed
• (Nelson et al 2002474)

8

• 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)

9
The Disconnected Disorder (adapted from
Arabena 2006)

• The disconnection between those engaged in
  developmental processes fuelled by an
  insensitivity to those who are most intimate with
  it

10
Dignity and Work (after Marx)

• Dignity is lost when workers are alienated from
• the products of their labour, that is they no
  longer determine what is to be made or how it is
  to be used
• the process of work, someone else controls the
  pace, techniques and processes of work and
  workers become emotionally separated from their
  work
• the ability to be creative, when workers capacity
  for self directed creativity is denied
• when workers are alienated from others, when
  group interactions are dictated by rigid
  hierarchies which determine who can relate to
  whom.

11
Dignity and the Patient

• I have been referred to so many people here, a
  Mr an orthopaedic surgeon, and my own
  consultant Mr looks after all my other things.
  I am now apparently referred to a Mr whoever he
  is, I dont know where I am in this place. I
  dont know who is going to treat who or what
• (Quote from a patient participating in a study
  of whole systems working, McCormack et al, 2005)

12
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)
13
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

14
What does Practice development have to Offer this
Agenda?
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)
15

• Practice development is a continuous process of
  developing person-centred cultures. It is enabled
  by facilitators who authentically engage with
  individuals and teams to blend personal qualities
  and creative imagination with practice skills and
  practice wisdom. The learning that occurs brings
  about transformations of individual and team
  practices. This is sustained by embedding both
  processes and outcomes in corporate strategy.
• (McCormack, Manley Wilson, in press)

16

• Practice development utilizes a number of key
  steps in systematically developing
  person-centered cultures, including

• Agreed ethical processes
• Stakeholder analysis and agreed ways of engaging
  stakeholders
• Person-centredness
• Values clarification
• Developing a shared vision
• Workplace culture analysis
• Collaboration and participation
• Developing shared ownership
• Reflective learning
• Methods to facilitate critical reflection (e.g.
  action learning)

• High challenge and high support
• Feedback
• Knowledge use
• Process and outcome evaluation
• Facilitation of transitions
• Giving space for ideas to flourish
• Dissemination of learning
• Rewarding success

Changing practices, team processes and workplace
cultures and enabling human flourishing
17
A Model of Active Learning
(Fink, 1999)
18
To achieve its purpose, active learning must take
on many shapes or guises, including talking,
writing, reading, discussing, debating, music,
walking, acting, role-playing, games, journaling,
interviewing, making displays and posters,
building sculptures, many forms of creativity,
imagining, visioning, theatre etc
19
What is Person-centeredness?

• Person-centeredness is an approach to
• practice established through the formation and
  fostering of therapeutic relationships between
  all care providers, care receivers and others
  significant to them in their lives.
• It is underpinned by values of respect for
  persons, individual right to self determination,
  mutual respect and understanding. It is enabled
  by cultures of empowerment that foster continuous
  approaches to practice development
• (adapted from RoI Older Persons National PD
  Programme Facilitation Team)

20
The Person- Centered Nursing Theoretical Framework
21

• Professionally competent
• Developed interpersonal
• skills
• Commitment to the job
• Clarity of beliefs and
• values
• Knowing self

22

• Appropriate skill mix
• Shared decision
• making systems
• Effective staff
• relationships
• Supportive
• organisational
• systems
• Power sharing
• Potential for
• innovation and risk
• taking

• Professionally competent
• Developed interpersonal
• skills
• Commitment to the job
• Clarity of beliefs and
• values
• Knowing self

23

• Appropriate skill mix
• Shared decision
• making systems
• Effective staff
• relationships
• Supportive
• organisational
• systems
• Power sharing
• Potential for
• innovation and risk
• taking

• Professionally competent
• Developed interpersonal
• skills
• Commitment to the job
• Clarity of beliefs and
• values
• Knowing self

• Working with patients
• beliefs and values
• Engagement
• Sharing decision making
• Having sympathetic
• presence
• Providing for physical
• needs

24

• Appropriate skill mix
• Shared decision
• making systems
• Effective staff
• relationships
• Supportive
• organisational
• systems
• Power sharing
• Potential for
• innovation and risk
• taking

• Professionally competent
• Developed interpersonal
• skills
• Commitment to the job
• Clarity of beliefs and
• values
• Knowing self

• Working with patients
• beliefs and values
• Engagement
• Sharing decision making
• Having sympathetic
• presence
• Providing for physical
• needs

• Satisfaction with
• Care
• Involvement with
• Care
• Feeling of Well-
• Being
• Creating a therapeutic
• Culture

25
The Person- Centered Nursing Theoretical Framework
26
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

27
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)

28
Issues to Consider

• Clarity about desired outcomes
• Strategic embedding
• Managers understanding
• Required expertise
• Service-user engagement

• Relationship between service and HEIs
• Integration of learning approaches
• Methodological development
• Outcomes evaluation PRAXIS framework
• Costing models