VOL: 97, ISSUE: 22, PAGE NO: 36
Steve Page, MSc, BA, RGN, is head of risk management and professional development at The Newcastle upon Tyne Hospitals NHS Trust and practice development programme associate at the Centre for the Development of Nursing Policy and Practice, University of LeedsInterest in practice development (PD) has grown in recent years, so much so that it has become an area of practice in its own right. However, the term tends to be used loosely and only a few authors have given it a more precise definition (Manley, 1997; Harvey et al, 1999; Clarke and Procter, 1999; Unsworth, 2000).
Interest in practice development (PD) has grown in recent years, so much so that it has become an area of practice in its own right. However, the term tends to be used loosely and only a few authors have given it a more precise definition (Manley, 1997; Harvey et al, 1999; Clarke and Procter, 1999; Unsworth, 2000).
Literature on the subject, combined with clinical experience, suggests that PD draws on a range of other disciplines, such as evidence-based practice, innovation in practice and continuing quality improvement. The term has also been used in the context of organisational development and managerial issues. But in spite of these overlaps, PD is more than a patchwork of ideas on change.
Those who work in PD must recognise the complexity of the clinical environment if they want to effect change and tailor any developments to suit the local context. Several authors have explored ways in which this might be achieved and their work has focused on models in which practice and academic partnerships have attended to the real practice setting (Kitson and Currie, 1996; Bell and Procter, 1998; Harvey et al, 1999; Antrobus and Brown, 1997).
The best known and most widely tested models for delivering PD are those of nursing and practice development units. In the early days, these concentrated on nursing, but more recently the value of interdisciplinary work has been recognised and there has been a consequent move towards the more patient-focused practice development unit (PDU) approach (Allsopp et al, 1998; Chin and McNichol, 2000; Walsh, 2000).
For some years, the Centre for the Development of Nursing Policy and Practice (CDNPP) at Leeds University has promoted the nursing development unit (NDU) and PDU approaches and fostered a more systematic process with a growing network of partners in their accredited units.
A framework is now beginning to emerge that can be used to illustrate and explore the characteristics of PD and what makes it effective.
Purpose of the framework
The framework (Fig 1) offers an overview of the range and scope of PD. It could be used by:
- Practitioners and leaders of PD - to identify strengths, weaknesses and priorities for development;
- Educationalists - to help students learn about the complexity of PD and the skills and knowledge needed to implement it;
- Organisations such as the CDNPP, which is interested in developing the theory and application of PD as well as models and behaviours that would facilitate its delivery;
- Researchers - to identify gaps in evidence and potential fields of study.
It is worth examining Fig 1 in detail. First, four different levels of PD are identified: individual, unit or team, organisational and supra-organisational. Second, the framework highlights the means by which PD can be delivered.
What might be called structure or approach relates to mechanisms that support PD: communication systems, supporting posts, forums, relevant policies, strategies and allocated resources. Process/deployment shows how these systems are used and how organisations and individuals work to bring about PD.
Finally, outcome/results refers to the measurable effects of the first two areas of activity and the benefits of PD to the delivery of care and service. At an individual level, this relates to personal behaviours such as learning, reflection and involvement in the developmental process, all of which run alongside the supporting structures that enable this to happen.
At unit or team level, PD focuses on a collaborative approach and the effectiveness of the team. An example within the NDU/PDU model is the unit steering group, which can help to guide and nurture the unit team by bringing a wider range of experience, skills and influence to bear.
Typically, a team might include an executive director, a senior academic from a local university and perhaps representation from relevant voluntary groups. A process/deployment element in this structure could be, for example, the involvement of team members in defining the philosophy and goals of the unit or in choosing the PDU accreditation process. Outcomes/results might include innovations and measurable improvements in evidence-based practice.
At the organisational level - trust or primary care group - the activity tends to emphasise the implementation of policy or standards while remaining focused on improving patient care. The structure/approach issues here might include PD support groups such as the nursing practice development group (NPDG) at The Newcastle upon Tyne Hospitals NHS Trust. This group was formed in 1998. Its membership includes:
- Nurses from wards and departments across the range of clinical specialties;
- A variety of nurse specialists;
- Others with a remit to support PD;
- Individual members of the clinical effectiveness and audit department training team and representatives from both local universities.
The NPDG is a forum for sharing ideas across this large and diverse trust. Process/deployment considerations might include communication and collaboration among units. For example, from projects initially undertaken by specific departments the NPDG has supported changes in practice that have improved care for patients in all directorates. The areas covered include the qualified nurse and support worker role, violence and restraint, and the provision of nurse escorts. Such work has shown how PD can be used to enable individual practitioners at ward/department level to influence patient care across the whole organisation.
Another example can be found at the Thurrock day hospital PDU in Essex, where leadership is shared in a locally developed model by a nurse, a physiotherapist and an occupational therapist, all of whom have responsibilities outside the PDU. This helps to build an interprofessional approach to PD and enables the unit to influence policy and practice on a much broader scale.
Finally, at the supra-organisational level the structure/approach could relate to networks or shared standards; process/deployment could include activities such as benchmarking and other work with outside organisations. Outcome/results at this level might include influencing broader policy or educational curricula, identifying research questions for the broader health community and sharing good practice.
For example, Ellis (2000) describes how a number of paediatric units formed a network in Lancashire to use benchmarking of clinical practice on areas such as pain management, the care of adolescents and care of children in the community. This approach is reflected in The Essence of Care initiative for benchmarking of basic clinical practices (DoH, 2000), which has recently been the subject of a national consultation. This shows the potential for clinically based developments to have a national influence.
At Nottingham Healthcare NHS Trust Rehabilitation and Community Services, the residential mental health practice development unit has recently achieved full accreditation from the CDNPP in Leeds. Here, innovative work is being carried out in areas such as patient and carer involvement in planning services, practice development project teams, feedback and evaluation, and staff selection panels. The PDU has liaised with the local university, other trusts and voluntary groups as well as the Sainsbury Centre for Mental Health. Work has been presented at the university to feed ideas into education and research and the PDU is beginning to use its experience and expertise to bring wider influence to bear through networks and conferences.
The CDNPP and its precursor organisations have been developing a systematic approach to PD for a decade, based on its accreditation of NDUs and PDUs. The framework described in this article will provide a useful vehicle for further development of this process. Future work will focus on specific aspects of the framework and attempt to develop an understanding of PD as a discrete discipline.