Practice Development: To What Outcome

1
Practice Development To What Outcome?

• Brendan McCormack,
• Professor of Nursing Research, University of
  Ulster
• Director of Nursing Research Practice
  Development
• Royal Hospitals Trust, Belfast
• Adjunct Professor of Nursing, Monash University,
  Melbourne, Australia
• Visiting Professor, University of Northumbria,
  Newcastle, England

2
Presentation Focus

• A Short Introduction to Practice development.
• Some Methodological Challenges.
• Evidence from a Systematic Literature Review.
• Issues and Challenges

3
The 5 minute history of PD!

• Origins in Nursing in Oxford in 1980s
• Spread through the NDU movement
• Variety of roles through 1990s-2000s
• Emergence of PDUs
• PD methods and conceptual frameworks (e.g.
  Garbett McCormack, 2002 Unsworth 2000 Manley
  2000 Clarke Procter 1999 McCormack et al
  1999 Binnie Titchen 1999 Mallett 1997)
• International developments (e.g. Australia, New
  Zealand, Holland)
• PD Book (McCormack, Manley Garbett 2004)
• Continuous growth in methodology developments
• Challenges re focus, methods, outcomes

4
Challenges to PD

• Multiple perspectives leading to lack of focus
• Poorly linked to strategic outcomes and
  modernisation agenda
• Overly focused on PD roles
• Overly reflective/introspective
• Lack of hard evidence to prove its worth
• A catch-all for poorly-specified change
  processes.

5
Claims made about PD

• Centrality of person-centred clinical
  effectiveness
• Facilitated approach
• Develops leadership attributes and skills
• Operationalises appreciative inquiry, critical
  inquiry and values clarification
• Enables judicious use of evidence
• Builds team effectiveness and new ways of working
• Increases staff satisfaction/retention and
  recruitment/stability
• Makes clinical governance and accountability a
  reality
• Changes the culture and context of practice
• Continuously evaluates and improves practice

6
Defining PD(Garbett McCormack 2002 2004)

• 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
  continuous processes of emancipatory change that
  reflect the perspectives of service users and
  service providers.

7
The Intent of Emancipation!
8
A realist synthesis of Evidence Relating to
Practice Development

• A study for NHS Education for Scotland and NHS
  Quality Improvement Scotland (July 2005 March
  2006)
• Professor Brendan McCormack Institute of
  Nursing Research, University of Ulster.
• Belinda Dewar Independent Research Consultant.
• Jayne Wright, Research Associate, Institute of
  Nursing Research, University of Ulster.
• Robert Garbett Institute of Nursing Research,
  University of Ulster.
• Dr Gill Harvey Senior Lecturer in Healthcare
  and Public Sector Management, Manchester Business
  School, University of Manchester.
• Ms Kay Ballantine -Sub-Librarian, Faculty of Life
  and Health Sciences, University of Ulster

9
Methodology

• Realist synthesis (Pawson et al, 2004)
• A method for studying complex interventions using
  diverse bodies of data
• Clear objectives and inclusion criteria
• Benefits
• Flexible but rigorous
• Capacity for providing detailed and practical
  recommendations

10
Characteristics of Complex Social Interventions

• Consist of theories
• Involve actions of people
• Consist of a chain of steps or processes that
  interact
• Constituent steps and processes are rarely linear
• Embedded in social systems
• Prone to modification
• Open systems that change through learning
• (Pawson et al, 2004)

11
The Realist Approach

• Review method based on principles of realistic
  evaluation
• Focus is on reviewing complex social
  interventions e.g. policy, management, service
  delivery
• Review takes place at the level of theories that
  underpin complex interventions
• Explanatory focus seeking answers to the
  question What works, for whom, in what
  circumstances, in what respects and why?

12
The Realist Review Template

• Clarifying the scope of the review
• Searching for evidence
• Appraisal of primary studies
• Data extraction
• Data synthesis
• Interpretation of findings/ presentation of
  results and recommendations

13
Figure 1 Model for conceptualising practice
development programme theories
14
Explanatory model for practice development
Outcomes for patients, staff and organisations
Leadership
Location
Culture
Context
Access
Scale of activity
BY WHOM?
WHO?
Level of involvement
Theoretical orientation
Knowledge
WHAT/ WHY?
HOW?
Starting point
Change
Focus of activity
Learning
15
Four Theories and 13 Theoretical Foci

• Theory area 1 - Properties of the people and
  context in practice development
• What impact does the extent of involvement of
  different stakeholders have on the outcomes of
  practice development?
• What impact does the scale of a study have on the
  outcomes of practice development?
• How do contextual factors in the study setting
  have an impact on the outcomes of practice
  development?
• How do cultural factors in the study setting have
  an impact on the outcomes of practice
  development?
• How do styles of leadership in the study setting
  have an impact on the outcomes of practice
  development?

16

• Theory area 2 Properties of the people involved
  in developing practice
• How does the location of a practice developer
  have an impact on the outcomes of practice
  development?
• How do the means by which the practice developer
  gains access to the practice environment have an
  impact on the outcomes of practice development?
• How do the methodological positions taken by
  practice developers have an impact on the
  outcomes of practice development?

17

• Theory area 3 Issues surrounding the initiation
  and carrying out of practice development
• How do factors involved in the initiation of
  practice development have an impact on its
  outcomes?
• What are the foci of practice development
  activity and how do they have an impact on its
  outcomes?
• Theory area 4 Approaches used to the use of
  knowledge, bringing about change and supporting
  learning in practice development
• How do approaches taken to support learning
  within practice development have an impact on
  outcomes?
• How do approaches taken to bringing about change
  within practice development have an impact on
  outcomes?
• What forms of knowledge use and knowledge
  generation are used in practice development and
  what are the consequences for the outcomes?

18
Search Strategy

• Map commonly used subject headings onto concepts
  emerging from commonly used definitions of PD
• 92 papers from existing database (2000-05)
• 771 classification terms used!

19
(No Transcript)
20
Classification of Papers Found
21
(No Transcript)
22
Grey Literature Sources
23
Telephone Interviews
24
Methods
1. Extraction of data from individual data
extraction sheets and inputting to theory
synthesis forms
2. Identifying themes from data in each theory
area
3. Draft report to the project steering group for
discussion, clarification, challenge
identification of gaps.
4. Input grey literature data from individual
data extraction sheets to theory synthesis forms
5. Identifying/ clarifying themes from data in
each theory area
6. Writing narrative (findings)
25
Findings 1

• What does the evidence tell us about theory area
  1 - Properties of the people and context in
  practice development?
• Unidisciplinary vs multidisciplinary approaches
• Multiple stakeholders
• Methodological implications

26
Findings 2

• What does the evidence tell us about theory area
  2 - Properties of the people involved in
  developing practice?
• Insider/outsider roles
• Organisational partnerships
• Working with practitioners and working for
  organisations
• Methodologies and methods

27
Findings 3

• What does the evidence tell us about theory area
  3 Issues surrounding the initiation and
  carrying out of practice development?
• Developing knowledge and skills versus bringing
  about particular practice changes
• Initiation of PD agendas

28
Findings 4

• What does the evidence tell us about theory area
  4 approaches used to the use of knowledge,
  bringing about change and supporting learning in
  practice development
• Learning approaches
• Relationship between development approaches and
  outcomes achieved

29
Methods
1. Extraction of data from individual data
extraction sheets and inputting to theory
synthesis forms
2. Identifying themes from data in each theory
area
3. Draft report to the project steering group for
discussion, clarification, challenge
identification of gaps.
4. Input grey literature data from individual
data extraction sheets to theory synthesis forms
5. Identifying/ clarifying themes from data in
each theory area
7. Consideration of themes from telephone
interviews against initial literature themes
6. Writing narrative (findings)
8. Data Synthesis Final themes and sub-themes
30
Final Themes
31
There is no evidence to suggest the superiority
of multidisciplinary over unidisciplinary
practice developments. Consistent with other
developments in contemporary healthcare delivery,
the review suggests a general sense of
multidisciplinary PD being better. However,
the key issue is that the decision should reflect
the overarching intent/desired outcomes of the
development work itself.
There is universal acceptance of the need for
service user involvement (or engagement) in PD
work. However, there is little evidence of this
happening in a proactive way currently and most
involvement is representative of consultation
rather than involvement.
The involvement of managers in PD is crucial to
the successful implementation of PD processes and
the sustainability of outcomes. However, the
evidence would suggest mixed-support from
managers for PD work. Managers need to understand
how PD can contribute to the modernisation and
development of effective services.
32
Collaborative relationships with HEIs can provide
an important means of reducing isolation for
practice developers, but also a way of extending
the potential for systematic and rigorous
processes to be adopted. However, the principles
upon which such relationships are established are
crucial to the success of such collaborations
Practice developers in formal PD roles continue
to experience isolation and role ambiguity. The
expertise required by practice developers is
largely unknown and unrecognised. There is a
need to develop a greater understanding of the
particular knowledge, skills and expertise needed
to operate in differing PD roles.
There is no evidence in the PD literature of
traditional education processes having a direct
impact on practice. Reflective learning
strategies and in particular action learning
appear to have more to offer the sustainability
of PD and there is a need for further evaluative
research in this area.
33
There is consensus in the data that effective
practice development requires the adoption of
participatory methodological approaches. No one
methodology is favoured. The diversity of
approaches appears to enable new knowledge about
effective processes to emerge.
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. The complexity of PD militates
against the correlation of any one method with PD
outcomes .
34
PD Projects should Demonstrate Use of the
Following Methods

• 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

35
There is consensus in the data that effective
practice development requires the adoption of
participatory methodological approaches. No one
methodology is favoured. The diversity of
approaches appears to enable new knowledge about
effective processes to emerge.
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. The complexity of PD militates
against the correlation of any one method with PD
outcomes .
There is no available costing model for PD. The
majority of PD funding is focused on the
resourcing of practice development roles.
However, as we move more towards an integrated
methodology of PD where the emphasis is on
particular processes rather than roles per se,
then costing models need to be developed.
36
Key Messages Outcome measurement in PD is complex
and does not lend itself to traditional methods
of outcome evaluation. The evidence suggests
that outcome measurement needs to be consistent
with the espoused values of participation and
collaboration where data collection and analysis
is an integral component of the development
itself. A wide range of outcomes are evident
from published practice developments and there is
a need for the replication of these in further
studies.
37
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)

38
Where Does This Leave Us?

• Technical PD Training?
• There is a need for strategic alliances in order
  to advance PD as an accepted methodology for
  transformative action and modernisation.
• Need to accept that PD is a complex intervention
  and methodology needs to reflect this
• Participation, inclusion and collaboration are
  essential components of a PD methodology.
• There are key PD methods and these need to be
  emphasised in PD work.
• There is a need to deemphasise PD roles per se.
• Evaluation frameworks need to reflect
  participation, inclusion and collaboration
  consistent with complex interventions.
• Outcomes at individual, team and organisational
  levels can be demonstrated from PD work.