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Practice development? Of what are we talking?

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  2. Practice development? Of what are we talking?
  3. References

Practice development is a continuous process of improvement toward increased effectiveness in person-centred care, through the enabling of nurses and healthcare teams to transform the culture and context of care. It is enabled by facilitators committed to a systematic, rigorous and continuous process of emancipatory change. (McCormack et al. 1999:256)

If McCormack is any authority on the topic (and I have good reason to believe he is) then this definition is as good a place as any to begin my editorial. The power to define is ascribed to very few and therefore McCormack can claim some fame for having attached his name to what has become a veritable cottage industry in the nursing profession in the short time since this publication, which in my investigations is one of the earliest to wave the PD flag, as it were, (In so doing of course, he is also obliged to shoulder some responsibility for it as well!). These days you might have noticed that a growing number of practice development people now populate the cultural landscape in nursing at a range of levels from facilitators, coordinators, directors and even professorial chairs. Well, in the UK and Australia at least. I have not seen the term or heard of practitioners of the art of PD in the literature from the USA. We are still a pretty parochial lot in nursing it seems (but more on this later).

Before I get properly underway, a caveat on method (if not a certain madness): my commentary and critique below issue from a deliberately self-deprecating and ironic posture in that my current substantive employment is as a practice development coordinator in a leading private hospital and many of my publications over the last seven years in this role both reflect and construct the reality of my work in practice development. Having put my cards on the table then, I want here to unpick the substance of this definition above to show how its rhetorical gestures threaten to render PD something of an emperor in new clothes.

Mary Fitzgerald, currently professor of nursing at James Cook University, at a PD conference and school in Melbourne a few years ago told us that practice development was ‘whatever anyone wants it to be’ (see Walker 2003). This deeply relativistic response to the ‘what is it?’ question sends the deconstructionist in me slightly mad. If PD can be ‘anything’ then ergo, it can be also, ‘nothing’. Practice development is, after all, not a proper noun in the strict sense of it having exclusive (i.e. capitalised) rights to name something (although I guess by virtue of continual usage, we have made it such). One would not find it in any dictionary; it is just two simple words stuck together by no more than mere happenchance of history and culture. The story of how they came to be so adjoined is for another time and another author but it would make for fascinating reading.

As I suggested above, the power to define is an onerous one and it begs conceptual clarity, semantic sophistication and epistemic substance. This definition before us embodies very little of these in my reading. However, it does orient itself around three key elements anything concerned with ‘practice’ and its ‘development’ should be oriented around: process, place and people.

Let us start with process. Practice development, in this definition, is clearly not a product, not a ‘thing’, and therefore, it is not able to be pinned down. Anything that is ‘continuous’ has no clear beginning and certainly no defined end. And if this is the case, it must surely be difficult to operationalise, let alone evaluate. In PD there is ostensibly nothing to evaluate but ‘increased effectiveness in patient-centred care’ which is indeed a difficult thing to demonstrate with certainty as it is by its very nature, subjective, ephemeral and intangible. Which aspects exactly of patient-centredness do we want to be more effective? Our levels of empathy and concerns for the other? Our attention to detail and ensuring the safety of our patients is tantamount? About what aspects of safety are we worried (and why)? You get my line of thought: the definition is so wide as to allow the passage of a very large ocean liner. You can perhaps now better understand why my colleague made the somewhat throw away remark about PD being ‘anything anyone wants it to be’!

Place in this definition, manifests in its mention of ‘culture’ and its ‘transformation’. This focus on the ‘context’ of care or culture places PD firmly in the domain of the politics of health and its ultimate realisation in hierarchies of convention and the important as well as the power/knowledge relations these spawn. This focus on transformational cultural change (what else might cultural change be if not ‘transformational’?) suggests that PD is more than simply finding better ways of providing health services and improving patient outcomes in that it seeks to change the very ground on which they are and can be played out. This is indeed a grand and ambitious agenda! It is too, I guess, the agenda I have been pursuing (with varying degrees of success) in my work here at St Vincent’s Private Hospital in Sydney. The work we have performed in the name of PD has been, until very recently, much more focused on transforming nursing culture than it has been on improving the effectiveness of patient-centred care. That is the next project and I have long argued that we cannot improve patient outcomes until we improve staff development and education, as well as tackle recruitment and retention while addressing recognition and reward. Now that we have achieved a number of our ‘cultural transformational’ goals at SVPH I believe we are very well placed to shift our focus to those in our care and already this has begun in earnest (see Walker 2007, 2005, 2003, 2002).

Finally, we have the focus on people and of which I have just talked (for one cannot talk about culture without talking about people). The inclusion of the need for a dedicated ‘facilitator’ is a curious one. It suggests that PD is something that must be named and given presence in the form of an independent resource; it enables professionals (such as me) to attach the term to their job titles and position descriptions and, ultimately, their publications. Indeed, this stipulation licenses a raft of people to preach and proselytise the ideals of practice development and thus spawn a new genre of nursing professional, as it were. In so doing, we (nursing) build (yet) another little empire in the greater realm of health care in which to create more and more hierarchies of the important and authoritative. For, as I mentioned at the outset, there is a presently a large and growing horde of practice development professionals operating in and around nursing, functioning at a range of levels from coordinators, managers and directors to professorial chairs. Perhaps then, it is timely to ask: Why practice development now? Why, given the unarguably commonsense, if not loosely configured, principles embodied in the definition above, have we not always had a need for something called practice development (if indeed, we have not long had people already performing in roles designed around that definition but not so precisely designated)? What politics might be in force to enable the appearance of practice development as a ‘thing’ in and of itself? For surely we have had squadrons of quality improvement coordinators, and risk managers, and staff development officers, clinical nurse educators, special project facilitators and so on: what have each of these people been doing if not something very close to this definition of PD?

It seems to me that our profession has long suffered from a form of attention deficit disorder, whereby our capacity to find an idea and stay attached to it for more than a passing moment, has been a feature of nursing’s cultural and political growth and development. In our search for status and prestige (in competition with medicine and allied health) we have desperately sought novelty or borrowed other’s ideas and given them a nursing spin. Let me proffer a few examples: I think, for example, of our brief seduction in the late 1980s with the ‘nursing diagnosis’ movement that issued from the USA during a time of febrile scholarly output as ‘nurse theorists’ attempted to give legitimacy to and aspire to greater authority for nursing ‘as a science’. Nursing diagnosis as an idea and a reality in Australia never took hold and it evaporated from view as quickly as it came to the boil in the pot of the latest new ideas (e.g. nursing ‘conceptual frameworks’; diagnostic-related groups; the nursing process, to name a few of the same era). I don’t believe nursing diagnosis gained significant traction even in the country of its genesis for the simple reason that it was rather a silly idea in the first place. Embarrassing really, that nursing would be so naive, if not arrogant, as to devise a new language to sit alongside a perfectly adequate one! Indeed, it smacks of desperation to me.

I think too, for example, of the short-lived but exciting re-profiling clinical practice received following the publication of Benner’s seminal: From Novice to Expert also in the late 1980s (Benner 1984). Her work impelled a rash of conferences, seminars and re-invigorated debate in Australia and beyond about ‘the centrality of clinical practice’ to the profession of nursing – which had been perceived throughout the 1960s, 1970s and 1980s to have ‘lost’ its way as the profession became preoccupied with its need to establish itself in the tertiary sector. This energy and enthusiasm was not sustained unfortunately and still today clinical practice suffers from an image problem (among others) manifest in continuing difficulties attracting and retaining quality nurses.

In Australia, as another example of our proclivity to be seduced by the latest purportedly ‘new idea’ on which to hang our identity and bolster nursing’s self-esteem as a discipline in its own right, ‘the body’ in nursing (re)surfaced as a topic of concern for academics, only to disappear shortly thereafter. This ‘event’ was based almost entirely on the publication of Jocalyn Lawler’s early 1990s book Behind the Screens (Lawler 1991), a work that went considerably further than any previous attempt to restore nursing’s focus on the corporeality of caring and the socio-cultural politics of nursing and patients’ bodies. There was a conference here, an article or two there but no substantive body of research ever followed this arguably seminal work. Nursing certainly could have re-claimed care of the body as one of its most significant contributions to health care and led the way in scholarship on the body but we gave this territory away to the sociologists and medical anthropologists instead.

The most recent novelty to grab the attention of our current leadership in nursing has been, of course, ‘evidence-based practice’. Alan Pearson’s arguably successful promotion of EBP in nursing is manifest in the Joanna Briggs Institute and the distribution of best practice guidelines for clinical practice. Unfortunately, I have to tell you that the idea and practice of EBP is nowhere to be seen in our institution except at the level of rhetoric. I suspect we are not alone in this. In my reading, the JBI exerts only a very limited pressure on the daily life of practicing nurses, and its presence is all but limited to the virtual world of the website. Of course, EBP is promulgated by the bureaucracy and the academy as the great shining light for better health care; how deeply it embeds in clinical practice remains to be seen however and I doubt I will live long enough to see it transcend its rhetorical status and become business as usual. Simply too much has to change in the current hierarchies of knowledge and practice for it to ever be more than a slogan or catch phrase.

But back to PD. If my thoughts above about the ‘tyranny of the new’ are even vaguely on the mark, then PD as an idea and a reality is as likely to join the many other innovations and re-inventions I have touched on above and become yet another passing fad. For its origins and development to date, could hardly be construed as a deliberate, relevant and rigorous, well planned and executed strategic manoeuvre on the part of nursing’s leadership. PD has simply surfaced on several planes (individual institutions, academic/clinical postings and positions, conferences, symposia and of course, a small but growing raft of publications) without any warning, and without much, if any, discussion about its worth or necessity. No one in nursing asked for PD but it has been delivered to us whether we want and/or like it or not. Money (research grants and the like) is now disbursed in its name and careers are launched and enhanced in its wake. But would nursing as a profession be any worse off were PD to slide from view tomorrow? I doubt it.

As I suggested earlier, nursing needs to be much more strategic about its place in the greater scheme of those hierarchies of authority and importance I have mentioned throughout. The only way to convince others (health bureaucrats, colleagues in medicine, allied health, patients) of our worth and contribution to the well-being of the community is to conduct compelling and useful programmes of rigorous and strategically focussed research into the ‘outcomes and effectiveness’ of our care and then ‘apply and translate’ the results from such research into clinical practice. Others have successfully taken this approach for a long time and yet it is perhaps our biggest failure that we have not better emulated their model. So vale PD, your time – always and already – has been and gone!

References

  1. Top of page
  2. Practice development? Of what are we talking?
  3. References
  • Benner P (1984) From Novice to Expert: Excellence and Power in Clinical Nursing Practice. Addison-Wesley, Menlo Park.
  • Lawler J (1991) Behind the Screens: Nursing, Somology, and the Problem of the Body. Churchill-Livingstone, Melbourne.
  • McCormack B, Manley K, Kitson A, Titchen A & Harvey G (1999) Towards practice development – a vision in reality or a reality without vision. Journal of Nursing Management 7, 255264.
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  • Walker K (2002) Project possibility: a model of care and the politics of change. Contemporary Nurse 14, 8695.
  • Walker K (2003) Practice development in a postmodern world: from rhetoric to reality. The Collegian 10, 1721.
  • Walker K (2005) Reaching for the stars: career advancement and the registered nurse. International Journal of Nursing Practice 11, 185190.
  • Walker K (2007) Fast-track for fast times: catching and keeping Gen Y in the nursing workforce. Contemporary Nurse 24, 147158.