VOL: 98, ISSUE: 11, PAGE NO: 34
Steve Page, MSc, BA, RGN, is head of risk management and professional development, Newcastle upon Tyne Hospitals NHS Trust, and practice development programme associate, the Centre for the Development of Nursing Policy and Practice, Leeds University
In recent years the concept of a health care service that is continuously adapting and improving to meet the needs of service users has been gaining ground. There has been growing emphasis on defining standards of practice, implementing evidence-based practice and encouraging innovation in organisations and clinical teams.
Clinical governance (NHS Executive, 1999) encouraged these initiatives. It remains central to the NHS modernisation agenda (Department of Health, 1998), which aims to drag the NHS kicking and screaming into the 21st century.
If the NHS is to meet the expectations of users and keep pace with technology, it must achieve some ambitious modernisation targets. However, many initiatives that set out to develop and improve standards, such as continuous quality improvement, research and development, clinical audit and evidence-based practice, have failed to achieve the required level of change and innovation in practice settings (Page et al, 1998; Clarke and Proctor, 1999; Ferlie et al, 2000). This has led to growing interest in practice development as a way of enabling clinical practitioners and teams to deliver innovative, patient-centred care.
This article considers the nature of practice development and highlights the potentially significant contribution it can make to the modernisation agenda at all levels in the health service.
What is practice development?
The term practice development covers a wide range of activities, including the introduction of changes in practice, the support and development of practitioners, setting standards and quality improvement. It is often used loosely and interchangeably with other terms, such as the implementation of research evidence. This has been highlighted in accounts of confused and inconsistent descriptions of practice development nurses’ roles (Sams, 1998; Glover, 1998).
However, practice development is distinct from other change management activities and can be defined in more precise terms. Much of the thinking about it has emerged from nursing and practice development units (NPDU/PDUs) (Williams et al, 1993; Vaughan and Edwards, 1995; Page et al, 1998; Chin and McNichol, 2000), and from other settings in which practice and academic partnerships have focused on real practice environments (Kitson and Currie, 1996; Antrobus and Brown, 1997; Bell and Proctor, 1998; McCormack et al, 1999).
Organisations such as the Centre for the Development of Nursing Policy and Practice at Leeds University have fostered the concept for a number of years. They have worked with a growing network of PDUs to develop a more systematic approach to practice development (Gerrish and Ferguson, 2000).
Practice development has the following key characteristics:
- It focuses on the improvement of patient care;
- It incorporates a range of approaches;
- It takes place in real practice settings;
- It is underpinned by the development and active engagement of practitioners;
- It is collaborative and interprofessional;
- It is evolutionary;
- It is transferable rather than generalisable.
It focuses on the improvement of patient care
The patient is the focus of the activity, rather than the practitioner, profession or department. Other benefits, such as cost savings or the enhancement of personal, professional or organisational reputations, may be by-products of practice development but are not its core objectives.
It incorporates a range of approaches
Practice development draws on and synthesises theory and activity from a number of fields, such as evidence-based practice, quality improvement and innovation in practice (Fig 1). The end result, however, is more than the sum of its parts.
It takes place in real practice settings
Practice development acknowledges the importance of context in developmental activity and the potential contribution of practitioners. Increased understanding of the complex dynamics of practice environments will aid the achievement of more meaningful innovation and change (Pediani and Walsh, 2000; Walsh, 2000a).
It is underpinned by the development and active engagement of practitioners
As it focuses on patients’ needs, practice development can succeed only when practitioners working directly with patients become engaged in the process. Clarke and Proctor (1999) suggest that practitioners need to integrate technical and theoretical evidence with the values and context of their practice environment. This is a fundamental criterion in the PDU accreditation scheme run by the Centre for the Development of Nursing Policy and Practice (Chin and McNichol, 2000).
It is collaborative and interprofessional
Patients’ needs do not cease at the boundaries and interfaces between departments, professions and organisations, and many problems and inefficiencies can be found precisely at these points. Practice development focuses on these interface issues and the importance of teamworking (Borrill et al, 2002). A collaborative approach also helps to maximise the creative potential of different skills and perspectives (Page et al, 1998; Walsh, 2000b).
It is evolutionary
Practice development is influenced by complex practice environments (Bell and Proctor, 1998; McCormack et al, 1999; Walsh, 2000a) and the creativity of practitioners. It is eclectic and complex (Manley, 1997), produces knowledge from practice (Ward et al, 1998) and can adapt to local context (Clarke and Proctor, 1999). As such, it may not be amenable to a rigid project management approach. Care development often evolves over time - there is not necessarily a ‘project’ with neatly defined start and end dates (Clarke and Proctor, 1999).
It is transferable rather than generalisable
Clarke and Proctor (1999) suggest that practice development is context-based and that knowledge generated from it cannot necessarily be generalised. But most can be described as transferable: it can be used in other settings, but may need to be interpreted or adapted to meet the needs of the specific practice context.
Practice development takes place on four levels (Fig 2). At the individual practitioner’s level it is about learning through and from practice, and thus improving personal or team care. At clinical team or unit level it is well described in the wealth of literature on PDUs. It may also involve activity at organisational level, as well as in the broader context, involving regional and national networks. Clearly, activity at each of these levels is connected, with the improvement of patient care remaining the focus. Depending on its specific emphasis, practice development may result in a number of possible outputs (see Fig 2).
The NHS modernisation agenda
A number of key priorities have been identified for the NHS (Department of Health, 2000). These are:
- Improving health: smoking, drugs and unwanted teenage pregnancy;
- Saving lives: cancer, coronary heart disease and stroke;
- Fast and convenient services: waiting lists and times, and modernising primary care;
- Caring for vulnerable people: mental health, services for older people and children’s services.
The modernisation agenda touches all parts of the NHS, both clinical and non-clinical, as well as other organisations, such as social services and higher education. To identify the real contribution of practice development, however, it is important to look at the underlying problems that necessitated the modernisation programme (Department of Health, 1998). These include:
- Inconsistent standards - between practitioners, departments and organisations;
- Old-fashioned demarcations between staff;
- Barriers between services;
- Inflexible, unresponsive services;
- Over-centralisation and the disempowerment of patients and staff.
Practice development can help to address each of these problems.
By involving practitioners at all levels in systematic enquiry, practice development makes it possible to tackle inconsistencies. For example, the nursing professional development group at Newcastle upon Tyne Hospitals NHS Trust discussed subcutaneous drug administration. Practitioners involved in other aspects of drug administration noted the paucity of guidance on the subject and inconsistencies in practice, so a practitioner-led audit was carried out across the trust. Comprehensive guidance was then produced and disseminated in partnership with palliative care and acute pain nurses, medical and pharmacy colleagues.
Practice development uses research and theory in a way that is sensitive to practice issues on the ground. This helps practitioners to engage with the evidence base. A project set up in Newcastle to implement recommendations on laxative prescribing for older people illustrates this. A multiprofessional group convened to consider the recommendations agreed that there was a need to look beyond prescription issues and consider patient assessment and management, interdisciplinary communication and ongoing management, including dietary issues. A detailed developmental project, underpinned by a practice audit, resulted in new clinical guidelines, changes to the prescribing formulary and widespread training for medical and nursing staff.
Finally, the emphasis on sharing good practice and benchmarking is the rationale behind practice development networks such as the Practice Development Forum (Kenworthy, 1996) and Centre for the Development of Nursing Policy and Practice’s Practice Development Alliance.
Old-fashioned demarcations between staff and barriers between services
As the patient is the focus of the activity, practice development is well placed to help break down barriers and address problems at service interfaces. It encourages links between different and often unconnected strands of activity, such as risk management, quality and audit. These activities usually run on parallel tracks, so the full benefit of an integrated approach may not be realised (Page et al, 1998).
In Newcastle in 1999, there was an explosion and fire involving a gas cylinder attached to a delivery-suite room warmer. A working group was set up. It included midwives and representatives from the estates department, medical devices, risk management, electrical-mechanical engineering, pharmacy, porters, health and safety advisers and the training department. The group’s many clinical and non-clinical recommendations have gone well beyond the issues raised by the original incident.
Observations made during a training session led to a discussion about the procedures for loaning portable oxygen cylinders for the use of children who were temporarily off the ward. Led by children’s services nurses, the working group developed clinical criteria for the use of oxygen, written information and training for parents, and a system to track this and other equipment to enable its recall and maintenance. The management of the original incident evolved into proactive practice development, made possible by cross-boundary working involving a wide range of clinical and non-clinical staff.
Over-centralised, unresponsive and disempowering services
The involvement of service users is integral to practice development. Similarly, it is underpinned by a culture of decentralised decision-making and calculated risk-taking. This encourages the clinical teams to come up with new, innovative ideas.
A recent accreditation visit to a prospective PDU at Thurrock Day Hospital highlighted some excellent examples. Conversations with patients revealed that some were unhappy with the day attendance pattern, which had been in place since the hospital opened. Some were attending for specific treatment, and not all wanted or needed the additional interactions and support provided. After a formal consultation with patients, the team implemented sessional attendance for those who wanted it. This has been refined after continued feedback from patients.
At the same hospital, discussions with patients and colleagues in the local acute trust identified the potential to carry out blood transfusions at the day hospital, avoiding overnight stays for patients who needed regular therapy. Protocols were developed, staff were trained and a new service was initiated, which has been evaluated positively by patients.
These examples illustrate the benefits that can arise when patients are involved and clinical teams are empowered to generate and implement new ideas.
The examples given illustrate some of the ways in which practice development can contribute to solving the problems associated with the modernisation agenda. Practice development is important because it does not rely on simplistic, top-down change strategies and is not seen as a separate bolt-on activity to everyday practice, but as integral to it. This is the main message of practice development and of models for its implementation, such as the NPDU approach.
A recent document outlining a regional plan for the implementation of the modernisation agenda (NHS Executive, 2000) states that implementing The NHS Plan requires ‘a sustained and intensive commitment to change from all staff. Ultimately the agenda can only be delivered by clinical teams and the services that support them. The task of the management community is to provide support to such teams in tackling this challenge’. If it is fully supported by both practitioners and organisations, practice development can play a significant role in achieving this goal.