Chapter 17
Weathering the seasons of practice development: moving towards a person-centred culture in complex continuing care1
Nadine Janes1, Barbara Cowie2, Jennifer Haynes2, Penney Deratnay2, Shannon Burke2 & Barbara Bell2
1Ryerson University, Toronto, Canada
2West Park Healthcare Centre, Toronto, Canada
Introduction
Evolving evidence on how to promote better practices in health care casts a spotlight on the context and culture of health-care settings as distinctly impactful. In particular, a culture of person-centredness within an organisation holds promise for creating the ‘right’ milieu or context for success in quality improvement work and ultimate transformations in care-giving practices. West Park Healthcare Centre (‘the Centre’), a Rehabilitation and Complex Continuing Care (CCC) facility in the province of Ontario, Canada, therefore adopted the Person-centred Nursing Framework in 2009 as a signpost for its interprofessional practice improvement work. A programme of work embedded in Practice Development (PD) methodology was initiated with the ultimate aim of shifting the culture of the Centre to one that was person-centred as defined by McCormack and McCance (2010). This chapter reflects the authors’ shared experiences and critical reflections on elements of the Person-centred Nursing Framework as a signpost for this difficult culture change work in the context of CCC.
The work in context
Canadian health care, a universally accessible system, is currently characterised by the ideology of managerialism with a drive for greater efficiencies and progressive waves of fiscal constraint, juxtaposed with demands for ‘quality’, ‘excellence’ and ‘best practices’ (Darbyshire 2008; Duncan et al. 2014). This context is not unique to our nation but rather parallels the pressures on systems across the globe.
The Centre formally took up the mandate to provide evidence-based interprofessional care in 2003 through corporate-wide processes based largely on project management strategies and best practice guideline implementation. While some practice improvement was realised over time, struggles with sustainability led us to a more critical reflection on our approach. What was revealed was our neglect of the socio-political context of our workplace (i.e. culture) in our practice improvement work. Consequently, in 2009 we selected the Person-centred Nursing Framework (McCormack & McCance 2006) to help structure our work going forwards and practice development (PD) as our methodology, appreciating its explicit focus on facilitating person-centred cultures. PD provides the theory and strategy to shift clinical practices in parallel to fostering the organisational milieu required to sustain and further build on improvements over the long term, the latter reflecting our missed opportunity during our initial practice improvement work.
Overview of the work
In 2010 we initiated an 18-month quasi-experimental study to evaluate PD as an approach to facilitating person-centred, evidence-based practice. What we present from here forwards is a mix of selected results from this study with the critical reflections of the authors, including some of what we learned about the Person-centred Nursing Framework as a guide to shifting workplace culture through PD methodology.
The practice development maple tree
Leadership for the PD work was provided by the Centre’s Professional Practice Department. We initially implemented PD across our seven CCC units relying on our five Advanced Practice Nurses (APNs) as lead PD facilitators, supporting the work of 11 Registered Nurses (RNs) as unit-based PD facilitators. The RNs were selected by the APNs in collaboration with unit managers using a standardised tool comprising qualities, skills and related behaviours identified in the literature as enablers of facilitator success (McCormack & Garbett 2003). The APNs and RNs attended a 5-day Foundational PD School at the onset of the work.
The Canadian maple leaf is a strong national symbol, centralised on the Canadian flag. The Canadian maple tree is therefore a fitting metaphor to share our Canadian PD work (Figure 17.1): the growth of our Centre’s person-centred culture. The trunk of the tree represents the philosophies and theories that underpin PD methodology. These include critical social theory, phenomenology, critical creativity and chaos theory (e.g. McCormack & Titchen 2006; Titchen et al. 2011), all of which give strength to the branches of the tree.
Figure 17.1 The growth of a person-centred culture through practice development (PD). APN, Advanced Practice Nurse; CCC, Complex Continuing Care; CIP, collaborative, inclusive and participatory.
The main branches of the tree represent the main foci of our work (see 1–7 in Figure 17.1) with the smaller deviating branches representing the specific PD methods we used to meet these foci. The branches reflect our attention to building the staff prerequisites and care environment fundamental to person-centred practices as per the Person-centred Nursing Framework, and to acting on the nine PD principles described by Manley et al. (2008, p. 5). Of note is the newest and therefore smallest main branch representing our seventh focus on interprofessional collaborative practice. This branch sprouted a year into our work when our data suggested the need to actively recruit clinicians beyond nursing staff as co-facilitators to enhance team engagement in and commitment to the work.
The leaves of the tree symbolise the learning we experienced. A maple leaf begins as a bud, unfolds into a brilliant green, turns golden with the coming of autumn, and finally dries up before falling to the ground where it nurtures the soil. We took deep reflective dives into our individual and organisational practices through cycles of learning that ultimately nourished our actioning going forwards. We present two of our learning leaves in this chapter.
The roots of the tree reflect what we have come to appreciate as the leadership traits that support the work. Administrative and clinical leaders need to embody PD and move beyond superficial ‘support’ for ‘doing PD’ (congruence). This includes what we have coined ‘being CIPy’ in all they do to reflect the Collaborative, Inclusive and Participatory nature of PD (collaboration). They need to take risks (courage) to challenge deeply entrenched behavioural norms (accountability) and resist reactive and atheoretical approaches to leadership that fall short in enabling their staff and patients to thrive (patience). The roots draw on the soil, which provides nourishment to the tree. The soil reflects the skilled PD facilitation that feeds the work and keeps it alive.
Finally, with the changing Canadian seasons comes the changing nature of the maple tree from budding glory in spring to snow-covered dormancy in winter. Our PD work is equally dynamic in nature, ever adapting and shifting with the changing climate of our organisation and our growth as PD facilitators.
The early facilitator experience
At three points in time during our formal study of PD, all facilitators participated in focus groups and 1:1 interviews to share their experiences of PD as a process for facilitating a person-centred unit-based culture. Data analysis led in part to the following narrative of the gestalt of the experience and the enablers and obstacles along the way.
The gestalt of the facilitator experience
Four themes emerged that captured the overall gestalt of the facilitator experience: a kaleidoscope of emotions, a shouldering of responsibility, an enduring belief, and a sense of aloneness.
Kaleidoscope of emotions. The emotive experience of being a facilitator can be likened to a kaleidoscope: a patchwork of highs and lows and everything in between. In response to the good moments, facilitators described being ‘happy’, ‘energised’, ‘keen’, ‘satisfied’ and ‘enthusiastic’. Conversely, when encountering the inherent challenges of their role, facilitators described experiencing PD as ‘painful and messy’, ‘demanding’, ‘scary’ and ‘draining’.
Shouldering responsibility. Facilitators carried a weight of responsibility. There is ‘lots on my shoulder’ as one facilitator described, itemised by others as expectations from peers and management to ‘be perfect’, to ‘solve problems’, to ‘motivate others’ and to ‘set an example’. These expectations were experienced by some facilitators as ‘beyond my ability’ at times and as a source of frustration. Conversely, other facilitators described feeling ‘excited’ by the responsibility they shouldered and ‘getting better’ at working through problems over time. The nature of the problems shouldered by facilitators ranged from histrionic, relational issues between staff that were particularly complex, to what one facilitator described as ‘everything’ including ‘petty things’ which she felt belonged in the ‘garbage bin’.
Enduring belief. Across all focus group sessions facilitators demonstrated an overall belief in PD as a ‘good thing’, a ‘phenomenally good concept’. They described it as something ‘needed’ and expressed belief in its ability to bring about ‘positive change’. This enduring belief existed despite the ‘hiccups in the process’ of PD. What appeared to help sustain the facilitators’ ability to ‘keep going’ and ‘see it through’ was an appreciation for ‘baby steps’. Facilitators acknowledged the need to be ‘flexible’, ‘strong’ and ‘confident’ as ‘change cannot come quickly’.
Sense of aloneness.
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