Chapter 9
An overview of practice development
Kim Manley
Canterbury Christ Church University, UK
Introduction
Person-centred care is a philosophy that values individuals’ own unique values, personality, personal history and the right of each person to respect, dignity and to participate fully in their life choices. This philosophy in health and social care embraces therapeutic and compassionate relationships between providers and patients/clients (Patterson et al. 2011; Dewar & Nolan 2013) and also between staff (Maben 2008; Kirkley et al. 2011; Maben et al. 2012).
Practice development has a long association with the development and provision of person-centred care, cultures and ways of working. Contemporary practice development is systematic, can contribute to the body of knowledge, focuses on using the workplace as the main resource for learning and development, and seeks to improve health and social care through developing and sustaining person-centred cultures. These cultures enable patients, clients and staff to flourish but also embrace knowledge translation in that the effective generation and use of evidence in practice is dependent on blending different knowledges, including people’s own expertise about themselves and their health.
Theoretical research into practice development (Garbett & McCormack 2002; McSherry & Warr 2008; Unsworth 2008) led to it becoming a search term in the British Nursing Index. Today, the purpose of practice development – person-centred care – is language increasingly embedded in policy and practice, research and quality strategies across organisations and systems (Health Foundation 2015; National Voices 2015).
This chapter provides an overview of practice development as a methodology in the context of developing person-centred cultures. It will provide a contemporary analysis of the current evidence base and will conclude with direction for professionals with a range of experience from individual to systems level.
Practice development: a methodology for developing person centred cultures
Methodology provides a set of principles that guide systematic activity in a particular discipline. For practice development, methodology became explicit in the late 1990s, when it was aligned to critical social science and the enlightenment, empowerment and emancipation of practitioners (Manley 1997; McCormack et al. 1999; Manley & McCormack 2003). Culture, facilitation and outcome evaluation became the focus of emancipatory practice development, affiliated with emancipatory action research and the development of transformational cultures (Manley 1997; Manley & McCormack 2003).
Concept clarification undertaken in parallel (Garbett & McCormack 2002; McSherry & Warr 2008; Unsworth 2008) led to describing the purposes, attributes and outcomes of practice development more specifically as developing person-centred care through working with cultures and contexts, enabling values and beliefs through systematic approaches that focus on learning in and from practice.
Realistic synthesis of the impact of practice development resulted in the identification of key methods (McCormack et al. 2006), summarised in Box 9.1. Major theoretical critique through the International Practice Development Collaborative led to further exploration of fundamental concepts: critical creativity linked to transformational practice development (McCormack & Titchen 2006); person-centredness (McCormack 2004); facilitation (Shaw et al. 2008); active learning (Dewing 2008) and work-based learning (Manley et al. 2009) as well as effective workplace culture (Manley et al. 2011a). In parallel, practice development has also been closely aligned with knowledge translation in that effective evidence translation is dependent on blending different types of evidence about the person, patient views, the local context, clinical experience and research (Rycroft-Malone et al. 2004; Lomas et al. 2005). Similarly, knowledge translation is reliant on skilled holistic facilitation and building enabling contexts and cultures (Rycroft-Malone et al. 2004; Rycroft-Malone 2013). Practice development methodology is summarised through nine principles (Manley et al. 2008) (Box 9.2).
Latterly, practice development as a broad approach to health and social care practice that overlaps improvement methodologies has also begun to be understood as a complex intervention, driven by the need to describe it as a research intervention, It is an approach that specifically uses collaborative, inclusive and participatory approaches to support the transformation of individuals, teams, practice and cultures to enhance the effectiveness of practices enabling all to flourish (Manley et al. 2011b). The concept of flourishing encompasses a person-centred approach (Titchen & McCormack 2010). Table 9.1 uses the five Medical Research Council (MRC, 2008) questions to guide the expression of practice development as a complex intervention. Whist the epistemological approach informing the MRC differs from that underpinning practice development it is nonetheless useful in reducing ambiguity about what can be expected when used as a programme intervention.
Table 9.1 Practice development as a complex intervention from the perspective of the Medical Research Council (2008) criteria
| MRC question | Practice development |
| What are you trying to do; what outcome you are aiming for? |
|
| How will you bring about change? | Using the Collaboration, Inclusion and Participation (CIP) principles to facilitate:
|
| Does your intervention have a coherent theoretical basis? |
|
| Have you used this theory systematically to develop the intervention? | Yes, from initial concept analysis of the intervention through to realistic synthesis and concept analysis of related concepts |
| Can you describe the intervention fully so that it can be implemented properly for the purposes of your evaluation, and replicated by others? | Specific criteria can be used to identify the presence of the intervention; these would include:
|
Adapted from Manley et al. (2013).
Box 9.1 Methods for practice development
Becoming person-centred, ethical, knowing self and others
- Agreeing ethical processes
- Being person-centred
- Knowing ‘self’ and participants
- Analysing stakeholder roles and ways of engaging stakeholders
- Being person-centred
Clarifying focus, values, culture
- Clarifying the development focus
- Clarifying values
- Clarifying workplace culture
Developing common direction through collaboration, inclusion and participation
- Collaborative working relationships
- Developing a shared vision
- Developing critical intent
- Developing participatory engagement
Facilitating reflection, ideas, transitions and incentives
- Continuous reflective learning
- Giving space for ideas to flourish
- Developing a reward system
- Facilitating transitions
Using effective strategies for communication, sharing and dissemination
- Good communication strategies
- High challenge and high support
- Implementing processes for sharing and disseminating
Evaluation
- Evaluation
Adapted from McCormack and Titchen (2006). Reproduced with permission of Taylor & Francis.
From a realist perspective, practice development would be considered a social complex intervention, recognising the influence and impact of context when used.
Box 9.2 Nine principles of practice development
Practice development:
- Aims to achieve person-centred and evidence-based care that is manifested through human flourishing and a workplace culture of effectiveness in all health-care settings and situations (Principle 1).
- Directs its attention at the micro-systems level – the level at which most health care is experienced and provided – but requires coherent support from interrelated mezzo and macro-systems levels (Principle 2).
- Integrates:
- work-based learning with its focus on active learning and formal systems for enabling learning in the workplace to transform care (Principle 3);
- the development of evidence from practice and the use of evidence in practice (Principle 4);
- 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 (Principle 5);
- evaluation approaches that are always inclusive, participative and collaborative (Principle 9).
- Is a complex methodology that can be used across health-care teams and interfaces to involve all internal and external stakeholders (Principle 6).
- Uses key methods according to the methodological principles being operationalised and the contextual characteristics of the programme of work (Principle 7).
- 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 (Principle 8).
- Directs its attention at the micro-systems level – the level at which most health care is experienced and provided – but requires coherent support from interrelated mezzo and macro-systems levels (Principle 2).
Adapted from Manley et al. (2008).
Realist evaluation begins with the researcher positing the potential processes through which a programme may work as a prelude to testing them. [p. 6] … Realism utilises contextual thinking to address the issues of ‘for whom’ and ‘in what circumstances’ a programme will work. [p. 7]
Pawson and Tilley (2004)
Developing person-centred cultures
Effective workplace cultures espouse and live person-centred values (Manley et al. 2011a),combining these with values about:
- 1. Working with others – open communication, high support and high challenge, involvement, participation and collaboration with stakeholders, teamwork and leadership development.
- 2. Effective care – evidence use and development, lifelong learning, positive attitude to change, holistic safety.
Other attributes of effective workplace cultures explain how values such as person-centredness are sustained:
- The values are realised and experienced in practice, there is a shared vision and mission with individual and collective responsibility.
- Adaptability, innovation and creativity maintain workplace effectiveness.
- Appropriate change is driven by the needs of patients/communities.
- Formal systems exist to continuously enable and evaluate learning; performance and shared governance embed the values in practice.
The stages in a culture change journey demonstrate how these attributes become embedded over time (Figure 9.1). Embedding values such as person-centredness in the workplace is associated with a number of transitions against which progress can be judged. Based on a readiness to want to engage, the journey commences with agreeing values and beliefs; then passes through transitions reflected by talking about what these values mean (values espoused); building mutual support and challenge across teams and organisations through feedback to enable values to be lived and inform decision-making; and finally, the introduction of systems (structures and processes) that will continue to embed and sustain values over time, as ‘form follows function’. In relation to person-centredness there is a continuum through which individuals and teams progress as they become more person-centred: starting with person-centred moments – ad hoc experiences of person-centredness – through to person-centred care as the underpinning culture of teams and organisations (McCormack et al. 2013).
Figure 9.1 Understanding the culture change journey.
Hence, the aim of practice development is to develop effective workplace cultures that have embedded within them person-centred processes, systems and ways of working, enabling all to experience person-centredness.
Current evidence base underpinning practice development
When considering the evidence base underpinning practice development in developing person-centred cultures, there are a number of relevant questions to ask:
- How would a person-centred culture be recognised?
- What is the impact of practice development on the development of person-centred cultures?
- What are the specific cultural change strategies that work?
- What difference does a person-centred culture make to health-care outcomes?
When determining how practice development as an approach achieves its impact on culture and establishing the significant aspects of the intervention, there are different philosophical approaches to consider. Culture is a complex social phenomenon and a nebulous social concept, where cause-and-effect relationships are difficult to establish, especially when there are so many multifactorial aspects to consider.
Insights from various research methodologies can contribute different aspects to understanding the culture change journey towards person-centredness, and this premise has guided the examples used rather than narrowly considering whether practice development has made a difference to culture. These insights will inform the future research landscape around the development of person-centred cultures. The diverse examples of different research approaches that follow illustrate this point.
How would a person-centred culture be recognised?
Person-centred cultures would be expected to consistently demonstrate as a social norm, person-centred values in action, based on a deep understanding by staff of what person-centredness means. Methods for identifying cultural attributes include the use of participant and non-participant observation or care and relationships, such as ‘Observations of Care’ (Royal College of Nursing 2006); Workplace Culture Critical Analysis Tool (WCCAT; McCormack et al. 2009) and other ethnographic approaches such as critical ethnography; and exploring experiences of patients, service users and staff to identify if there is a gap between what is espoused and spoken about and the lived experience of patients, service users and staff. Tools that can be used for this purpose include: emotional touchpoints (Scottish Health Council, 2014); patient stories (Royal College of Nursing 2006); questionnaires, such as the person-centred nursing index (Slater et al. 2009); and documentary analysis.
Kirkley et al. (2011) from a social care perspective, identified that views of person-centred care can often be diverse, and understanding person-centred care was one of five themes that influenced whether organisations were in a position to develop cultures to deliver on it.
Barriers to implementing person-centred care identified by Kirkley et al. (2011) included resource constraints, knowledge, attitudes and personal qualities of staff. Enablers were leadership style, and how managers support and value staff.
What is the impact of practice development on the development of person-centred cultures?
At the national level in Ireland, McCormack and colleagues (2010) implemented a programme in older people services using practice development and the Person-Centred Nursing Framework of McCormack and McCance (2006), using cooperative inquiry. They were able to identify the impact the programme had on staff (nursing and care staff), who achieved many of the prerequisites of the person-centred framework and changed significantly their perceptions of caring towards a non-technical conception. Residents and families also experienced qualitative changes in the care cultures around hope and hopelessness, choice, belonging and connectedness, and meaningful relationships, suggesting that the social norms were changing towards those that are more person-centred. The researchers highlighted the need to constantly support teams in this ongoing endeavour if person-centred cultures were to continue to develop and be sustained.
One comprehensive doctoral study (Osbourne 2009) using longitudinal design sought to evaluate the impact of emancipatory practice development across a large acute teaching hospital in Australia, although the focus was more on developing a context and culture that emphasised inquiry and evidence-based practice rather than person-centredness, which was an aspect of the study. This study was able to show through using an extensive number of validated tools, the effectiveness of practice development methodology in changing the culture and context of care through the attributes of autonomy and control, workplace empowerment and constructive team dynamics, which were connected to engagement with research and evidence inquiry.
The focus on the team culture and engagement approaches that enable workplace empowerment through an organisation-wide programme endorses the view that evaluating workplace culture is a powerful indicator of whether organisational values such as person-centredness are lived out in practice.
Beckett et al. (2013) demonstrated the impact of using practice development in an action research project in inpatient mental health with nursing and multi-disciplinary team members, and showed the importance of transformational principles at all levels of the organisation; a solution-based approach resulted in a development plan encompassing person-centred care amongst other themes.
McCance et al. (2013) were also able to affirm the value of using practice development to promote person-centredness through key findings showing: (1) that shared processes enabled engagement; (2) the impact of context on person-centred practice; and (3) the living of person-centred values. Preparedness and willingness to engage were identified as essential precursors. The key processes accounting for these changes included:
- focused on understanding person centeredness;
- developing a shared vision;
- determining the quality of the user experience;
- systematically developing practice;
- celebrating success.
What are the specific cultural change strategies that work?
In addition to those strategies above identified by McCance et al., a review of 82 practice-related projects, funded over ten years and supported by the Foundation of Nursing Studies (FoNS), was undertaken with the aim of identifying insights into creating caring cultures (Manley 2013). The projects were based on practice development, research implementation, practice-based research or a combination of these approaches. An impact framework informed by the attributes of effective cultures was used to evaluate these projects (Manley et al. 2013a). The review aimed to identify the espoused values, beliefs and attitudes, including person-centredness, that influenced the focus of each project, and to ascertain whether these values were more evidenced at the end of the project through documentary analysis. The project also aimed to draw out the processes influential in changing the culture.
The 82 projects were classified into five groups: (1) pure research, (2) implementing evidence, (3) practitioner-led service improvement projects, (4) practitioner-led using practice development principles, and (5) action research with/without practice development principles. Many of the projects involved working with service users in a person-centred way. Practice development typologies (group 4) and also action research (group 5) intentionally addressed workplace culture through working with person-centred values and the patient experience and the other attributes of effective workplace cultures. Group 4 and group 5 projects deliberately used tools and processes to implement values and drew on eclectic approaches to engage and work with stakeholders, working together using practice development principles. These approaches associated with groups 4 and 5 were more successful in making changes and sustaining caring, person-centred and effective workplace cultures, to the extent that this could be concluded for documentary analysis alone. However, none of the projects identified the importance of embedding person-centred values through implementing systems that embed these.
In a collaborative inquiry across three different projects, all drawing on practice development principles to take forward some aspect of person-centred care, ‘action hypothesis’ was used to identify the strategies that consistently appear to demonstrate similar outcomes (Manley et al. 2013b). Two common trigger points were identified across the three projects, related to developing effective workplace cultures (defined as being person-centred), specifically:
- Lack of common shared purpose/vision in relation to the project focus (Trigger 1).
- Unreceptive/underdeveloped workplace cultures characterised by such factors as lack of feedback processes/systems/evaluation/professional networks, support and challenge (Trigger 2).
The strategies used across the three projects were similar and found to be influential in all three projects to achieve similar outcomes. Figure 9.2 illustrates the action hypothesis resulting for Trigger 2 to demonstrate this synthesis of understanding.
Figure 9.2 Developing a culture of effectiveness. From Manley et al. (2013b).
Action hypothesis has much in common with realist evaluation where there is potential for identifying the mechanisms, contexts and outcomes that describe how person-centred cultures are developed. Within a project funded by Health Education England, realistic evaluation has been used to generate four transformation theories that account for how individuals’ professional practice and team cultures amongst other aspects can achieve person-centred care through describing and explaining the relationships between context, mechanisms and outcomes based on extensive reconnaissance through literature analysis and stakeholder engagement. These transformation theories for continuous professional development are linked to indicators at the individual, team, service and organisational levels, including person-centred practice (Jackson et al. 2015).
What difference does a person-centred culture make to health-care outcomes?
There is a growing relationship between person-centred workplace cultures and impact in a number of areas: for example, whether care is experienced as person-centred, whether learning is embedded, research is implemented, and the achievement of staff well-being, quality care and patient safety. The potential for practice development as a complex social intervention to contribute to the broader health-care agenda is proposed through using the attributes of effective workplace cultures as process indicators that signpost the potential for achieving the broader health outcomes (Manley et al. 2011b). This is an area that requires more substantial investigation.
Direction for practitioners with a range of experiences
The purpose of this section is to help practitioners consider how they may either contribute to or facilitate the development of person-centred cultures using practice development through perspectives at four different levels:
- building effective relationships;
- building effective teams and workplaces;
- embedding organisational values in systems;
- building whole systems approaches through clinical systems leadership.
- building effective teams and workplaces;
Building effective relationships
Building person-centred relationships is one of the ways that culture can be changed, so practitioners in health and social care settings can begin to influence this by reflecting on their own relationships. Through systematic inquiry at the individual level we need to continue to develop our self-awareness, to know our own values and beliefs, and what these mean in the context of daily work as a practitioner, team member, preceptor, mentor and critical companion. Self-awareness is a prerequisite for enlightenment, becoming empowered and freeing oneself from the things we take for granted in everyday life. Whilst there is much that can be done on one’s own in terms of rigorous reflection, it is important to obtain support through clinical supervision, critical companionships or peer support and challenge. This will help us to obtain different perspectives, to push our insights further, to become aware of the consequences of our actions on ourselves and others, and prevent us from deluding ourselves or accepting assumptions uncritically in our relationships or the influence of social norms in the workplace.
Box 9.3 makes five suggestions about building effective relationships that will help you become more person-centred: self-assessment against emotional competence (the prerequisite for effective relationships); developing a rigorous approach to reflection; obtaining feedback from colleagues about support and challenge; engage in caring conversations (Dewar & Nolan 2013); and using emotional touchpoints (Scottish Health Council 2014).
Box 9.3 Developing relationships
- 1. Assess yourself against the emotional competence framework and areas around emotional intelligence to understand your strengths in relationship building and the areas you need to develop (http://www.eiconsortium.org/pdf/emotional_competence_framework.pdf ).
- 2. Develop your approach to rigorous reflection by testing out a range of different models that support you in this activity.
- 3. Obtain feedback from your colleagues about how supportive and how challenging you are based on the premise that high support and high challenge are required for effective working and that people’s perceptions are different. The only way to become more person-centred and getting to know the people we work with is to ask for feedback.
- 4. Engagement in appreciative caring conversations with patients, their families but also colleagues and students too, as identified by Dewar and Nolan (2013):
- Know who I am and what matters to me?
- Understand how I feel about my experience?
- Work with me to shape the things that are done?
- Know who I am and what matters to me?
- 5. Use emotional touchpoints to find out what matters to patients, relatives, staff and students (Scottish Health Council, 2014).
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