Editorial writing affords one the opportunity to side-step many of the conventions of academic writing. And so it is a pleasure to have the opportunity to ‘dance’ with something that I feel so passionate about, and which to some it would appear, has become my own personal ‘cottage industry!
At a recent meeting of colleagues working across two universities in the UK we undertook a ‘getting to know’ you exercise as a means of starting the meeting and engaging with each other as ‘people’ rather than the academic label we came with to the meeting. One person used this opportunity to speak with some passion as to why she had moved from a practice leadership position to a role in the university; this led the way for other members of the group to follow-suit and relay their stories as to why they no longer worked in clinical practice full-time. Common to all our stories were several issues – first, few if any of us really wanted to leave practice, but felt that we needed to pursue other interests and passions; second, everyone felt disenfranchised by the dominant cultures of practice and felt the need to separate from its ‘everydayness’ to continue to flourish; and finally, the experience of practice (good and bad) continued to be the driver for wanting to undertake practitioner research and practice development research. As we reflected on our conversation, we postulated that we were probably ‘typical’ of many nurses who left practice for similar reasons but who may not have had the opportunity, as we have had, to continue to engage in the development of practice through their development and scholarly activities.
The conversation however, also highlighted a sadness we felt that practice and practice context, the heart of nursing, did not provide the kind of conditions that enabled us to flourish and pursue the ‘curiosities’ we all had. Whilst we each had differing methodological opinions about practice development, we all agreed, that our central motivation for continuing to engage in it was the drive to create workplaces that enabled people to flourish, that accommodated difference, that constantly transformed and that had person-centredness at their core.
Therefore, as I reflected on this conversation further and thought about Walker’s (2008) challenges that practice development can ‘be whatever we want it to be’ and that it is a passing fad, it seemed to me that these challenges are easy hits at a programme of work that has been (formally) in existence since the early 1980s. Nevertheless, Walker poses an interesting issue, i.e. can practice development be whatever we want it to be? And my response is, of course it can! Many years of experience, research and theory development would tell us that clinical practice in nursing is a complex activity. The nature of practice means that it is more than the completion of tasks, but instead is comprised of social, discursive, cultural and material conditions (after Kemmis & McTaggart 2005), all of which blend together to make a complex cocktail of interactions and engagements. The evidence-based practice movement has had to learn that providing people with information and audit tools is not enough to change practices and currently unravelling the complexities of practice context is a key focus of much research and development activity in this field (e.g. Cummings et al. 2007). Conway and Fitzgerald (2004) articulated how knowledge constituted as ‘practical interest’ (after Habermas 1972), even if rigorously developed and disseminated, is insufficient to change practice, an assertion reinforced currently by the experience of one of the PhD students with whom I work (Donna Brown). Donna demonstrated that, even after a 12-month rigorous ethnography of practice, the clinicians on the ward, whilst appreciating more fully the issues that prevented them practicing effectively, were unable to change those conditions and practice remained the same (Brown & McCormack 2006). However, a two year follow-up emancipatory practice development project resulted in extensive changes to the practice context, the conditions of practice and clinical practice itself.
Nursing, however, cannot hold its head high when it comes to misplaced and misjudged developments and our landscape is littered with the debris of many of these. The need for quick-fixes and rational objective technical and behaviourally driven solutions for what are often intractable problems and challenges is highly addictive among nurse managers and directors of nursing! So yes, practice development can be whatever we want it to be, but there are consequences. The ad hoc, quick-fix mentality that has dominated nursing development and healthcare reform has performed little to show sustained evidence of transformational change, and indeed, I would be bold enough to suggest that it has caused many of the vagaries of nursing that dominate the contemporary discourse (recruitment, retention, satisfaction and commitment for example).
Therefore, for me, practice development is a systematic and rigorous approach to working collaboratively and inclusively with clinicians and service users using participatory and critical engagement in the transformation of the social, cultural, discursive and material conditions of practice, to bring about person-centred cultures. Developing person-centredness is at the heart of practice development and despite much policy and strategic rhetoric, practice development continues to be the only methodology that has the development of person-centredness as its primary purpose and which recognises that person-centredness is not developed through one-off change events. Instead, it needs continuous reflective and critical relationships to be developed and sustained over time. Practice development pays attention to the ‘patterns of practice contexts’ (McCormack et al. 2008) that hinder clinical effectiveness. Patterns of decision-making, power use, conflict, relationships and learning are all the key foci of practice development. Over the past 10 years, significant conceptual, theoretical and methodological advances have been made in the development of frameworks to guide practice development activities. Of most significance has been our increased understanding of key concepts underpinning practice development work irrespective of the methodological perspective being adopted. For example, workplace culture, person-centredness, practice context, evidence, values and approaches to action learning for sustainable practice. Several researchers have explored the meaning of practice development through conceptual analysis, action inquiry and evaluation. This body of work has enabled an increasing sophistication in the systematic approaches to practice development.
In a recent systematic review of the evidence underpinning practice development, we (McCormack et al. 2007a,b) identified methodological principles that underpin all practice development work (collaboration, inclusion and participation), 18 methods that are systematically used in the development of practice and outcomes arising from development work undertaken, including, implementation of patient care knowledge utilisation projects; development of facilitation skills among staff; development of new services; increased effectiveness of existing services or expansion of more effective services; changes in workplace cultures to ones that are more person-centred; development of learning cultures; increased empowerment of staff; role clarity and shared understanding of role contributions; development of greater team capacity and the development of frameworks to guide continuing development (e.g. competency frameworks; integrated care pathways). This is not an insignificant body of work for something that is criticised for being a ‘passing fad’.
However, of course, practice development cannot claim exclusivity over outcomes such as these as research methodologies such as action research can also claim many of these outcomes. As somebody who undertakes and supervises much action research, I am only too well aware of the overlaps with practice development. Practice development has always got to be careful that it is not research by the back-door. The more systematic and rigorous that practice development becomes, the more distant from the everydayness of clinician and patient experience it also becomes and the more alien in terms of its operationalisation. It is always of interest to me that clinicians can be so ready to participate in facilitated development labelled as ‘practice development’ but yet will reject the same or similar work framed as research. This is not to suggest that practice development is actually sloppy and poorly constructed research, quite the contrary. Unlike research, practice development has the primary intention of developing practice and the development of new knowledge is a secondary intent. For researchers undertaking practice development we have to be careful that the ‘tail doesn’t wag the dog’ by reversing these intentions. Of course, researchers can claim that their research has achieved many of the outcomes from practice development identified earlier; however, the key question is who owns these outcomes? In some of my current practice development work, developing residential aged care practice in 22 units across the Republic of Ireland, 28 facilitators (22 of whom are staff in clinical practice) are working with over 250 multidisciplinary staff and older people undertaking systematic practice development. Through the collaborative, inclusive and participatory methodology adopted, these teams are changing practices, learning about the challenges of sustaining person-centred cultures and developing a range of new skills to ensure the ongoing engagement with the development of practice. However, of most significance, the outcomes achieved are their outcomes. Whilst many of these participants are engaging in activities that could be labelled as ‘research’ that is not how they see it and first and foremost for them it is about their and their colleagues practice. The identification of transferrable learning, the publication of findings and the securing of (research) grants are not their primary concerns. Practice development has empowered many clinicians to take control over their own practice, to use tools and processes to analyse their practice critically, to adopt facilitative ways of engaging that enable dialogue to happen and a shared understanding of practice foci to be realised, all with the intent of challenging and changing the same conditions of practice that drove me and my colleagues away from it.
Therefore, what excites me about practice development is not the definitions and debates about the utility of these, it is also not about whether there is a need or not for practice development roles and it is even not about whether it continues to exist or not into the future. What excites me is seeing clinicians change their perspectives about what is possible in practice, re-igniting the excitement of practice, creating spaces where dialogue leads to service-users and staff flourishing and releasing their potential and where intractable problems appear to fade into the mist of the past. As long as I continue to see this excitement that comes from overcoming the challenges of practice then I will continue to fly the flag for practice development!!
But will it continue in the future? Who knows. Does it matter? Not really. What matters is that we continue to strive to develop systematic and rigorous approaches to enabling clinicians to critique their practice and to helping clinicians and leaders to transform the conditions of practice that at times seem insurmountable. It also matters that we never loose sight of the fragility of person-centredness and realise that without continuous and systematic approaches to the altering of practice patterns, person-centred cultures fail to exist. As long as practice development in all its shapes and guises helps me and others to achieve these things, then it will be my approach of choice.