Towards practice development — a vision in reality or a reality without vision?

Journal of Nursing Management, 1999, 7, 255–264

Towards practice development — a vision in reality or a reality withoutvision?

B. McCORMACK dphil(oxon), bsc(hons) nursing, pgcea, rgn, rmn1, K. MANLEY mn, pgcea, rgn2, A. KITSONdphil, bsc(hons), rn, frcn3, A. TITCHEN dphil(oxon), msc, mcsp4 and G. HARVEY phd, bnurs, rn, rhv, dn5

1Head of Practice Development and Co-Director Gerontological Nursing Programme, 2Senior Fellow (PracticeDevelopment), 3Director, 4Development Fellow and 5Head of Quality, Royal College of Nursing Institute, RadcliCeInfirmary, Oxford, UK

Correspondence mccormack b., manley k., kitson a., titchen a. & harvey g. (1999) Journal of NursingB. McCormack Management 7, 255–264Royal College of Nursing Towards practice development—a vision in reality or a reality without vision?InstituteRadcliCe Infirmary This paper describes the development of a conceptual framework for practiceWoodstock Road development. Drawing on the authors’ combined experiences of facilitating developmentsOxford OX2 6HE

in practice, a conceptual framework is proposed. It is argued that much practiceUK

development in health care today lacks a systematic approach and is often undertaken byindividual practitioners who are poorly prepared for their roles. A short history ofpractice development is outlined to contextualize current development activities. Theproposed framework is located in a critical social science philosophy and it is suggestedthat such a philosophy enables individual growth and development, empowerment ofpractitioners and the generation of cultural change that sustains continuous growth andinnovation in practice. An example of the framework in use is described andrecommendations proposed to enable organizations to embrace a systematic approach topractice development.

Accepted for publication: 5 May 1999

Introduction ‘have practice development’ in an organization, given thatthe roles that are given a practice development label vary

‘Practice development’ has become a common phrase infrom executive nurse level through to individual prac-health care. Various strategic initiatives extol the virtuestitioners undertaking specific projects as an integral com-of organizations continuously developing the quality ofponent of their day to day practice?the patient’s health care experience and the professional

This paper sets out to address this debate through andevelopment of those who deliver services (DoH 1997;inductively derived analysis of practice developmentDoH 1998). Increasingly in the nursing and health careactivities undertaken by the Royal College of Nursingpress health care providers are advertising practice devel-(RCN) Institute over the past 10 years. In addition, itopment positions using a variety of role descriptions. Thisplaces into context much debate that exists about there-introduction of practice development roles reflects anature of practice development and whether or not itrecognition of the need for the development of servicesrequires a specific set of skills, knowledge and competence.and practitioners that to a large extent had been erodedThe paper is intended to reflect the diversity of views andthrough the development of managerial ideology in health

care systems (Traynor 1996). But what does it mean to perspectives within the RCN Institute and our emerging

255© 1999 Blackwell Science Ltd

B. McCormack et al.

conceptual clarity about the nature of practice develop- facilitators committed to a systematic, rigorous andcontinuous process of emancipatory change.ment. In order to do this, some important contextual

underpinnings of practice development will firstly be The key elements of this definition include an emphasison practice development being a continuous commitmentexplored. Through an analysis of the variety of perspec-

tives currently existing, a conceptual framework for prac- to improvement that focuses on the implementation ofeCective person-centred care (Hope 1996; Kitwood 1997).tice development will be proposed. It will be argued that

a framework for practice development is best located However, this is not just about the changing of a particularpractice intervention, but necessitates a focus on changingwithin a critical social science philosophy at patient,

organizational and strategic levels. Also, the need for a the culture and context in which care is delivered. Sucha focus is enabled through skilled facilitation centredsystematic approach that integrates learning, development

and research activities will be identified as central to a within a philosophy of emancipatory change, achievedthrough processes of enlightenment and empowermentsuccessful practice development strategy.(Fay 1987).

Practice development is messy, a reality that is oftenA working definition

overlooked in linear approaches to change management(see for example, Haines & Jones 1994; NHSE 1996).There is little doubt that nursing is a complex activity

that necessarily needs to respond to the changing needs Indeed Schon (1991) argues that eCective change occurswhen the messy world of practice is recognized as theof individuals, families and communities in a health care

system that is continuously changing. While ‘change’ is reality of practice (the swampy lowlands), while ineCectivechange occurs through a position that he describes as ‘therecognized as a complex activity (Kitson et al. 1998), the

importance of nursing remaining at the forefront of moral high-ground’ whereby the reality of the practiceworld is ignored or superficially acknowledged. Whilepractice developments is paramount to its continuous

existence as a service profession. Current developments recognizing the importance of getting research into prac-tice, it needs to be acknowledged that nursing practice isin health care provide opportunities for growth and

development in nursing practice, while simultaneously responsive to behaviours and needs of individuals whichmay be neither systematic nor logical. Greenhalgh et al.exposing threats to the core philosophy of ‘caring’ that

nursing espouses (Savage 1995). (1997) suggest that attempts to base all practice onresearch-derived evidence as a substitute for clinicalDevelopment has been defined as ‘the planned system-

atic process of implementing change’ (DoH 1993). expertise is a naıve ideal. However, placed within thecontext of practice development, basing practice on evi-However, current developments in adopting principles of

‘evidence-based practice’ are beginning to challenge the dence becomes a participative client-centred process,which integrates research with client preferences and‘naıve’ view of change through a linear, input and output

approach (Kitson et al. 1996; Kitson et al. 1998). The clinical expertise (Dawson 1997). It has been suggested(NHS Confederation 1997) that traditionally a haphazardRCN Institute has, for the past 5 years in its approach to

enabling nurses and other health care practitioners to combination of individual clinicians’ self-motivation anda collegiate system of peer-to-peer communication andsystematically develop practice, facilitated (among other

activities) a residential ‘summer school’ focusing on the support has been relied upon to bring about change. Thishaphazard approach contrasts sharply with the systematicdevelopment of knowledge and skills in practice develop-

ment. During the activities of these schools, questions are approach introduced in the earlier definition oCered andone which has been continuously evolving.explored about what practice development means and

inevitably this leads to a discussion about the lack of theconsistent use of a commonly agreed definition. Drawing

The context of development activitieson the views of course participants, institute facilitators,educators, practice development and research staC, the In British nursing there have been two broad areas of

practice development during the period 1978–96; firstly,following working definition of practice development hasbeen adopted to inform the development of the institute’s reform from ‘traditional’ styles of practice which focused

on tasks and ‘division of labour’, towards a more person-strategic position in practice development:Practice development is a continuous process of centred approach matched with the development of appro-

priate work organizational designs to support suchimprovement towards increased eCectiveness inperson-centred care, through the enabling of nurses changes. Secondly, the development of a ‘quality assur-

ance’-based approach in which nurses developed, moni-and health care teams to transform the culture andcontext of care. It is enabled and supported by tored and evaluated their own standards of care,

256 © 1999 Blackwell Science Ltd, Journal of Nursing Management, 7, 255–264

Towards practice development

informing and being informed by national developments making (Meleis 1991). Evaluation of these developments,however, predominantly focused on the development ofin quality assurance systems.

The previous traditional style of practice emphasized the profession of nursing (Pearson 1992) and studies thatattempted to measure the impact on patient outcomethe service of medicine as a means of serving patients and

was primarily concerned with the dutiful completion of were fraught with methodological problems (Pearson1992; Pearson et al. 1992) and were largely criticized fora hierarchy of practical tasks (Binnie & Titchen 1998).

The most appropriate and eBcient work design for this adopting ‘soft’ research approaches (DoH 1993). It is alsorecognized, however, that the caring ideology that nursingstyle was influenced by the industrial production-line

model in which tasks were completed in the least possible espoused throughout this period and which acted as thedriving force for much of its development was in conflicttime, by the appropriately qualified nurse. It has been

widely recognized that the lack of continuity of care, with the dominant managerial ideology of health care,with its emphasis on eBciency, throughput, productivityhowever, denied patients the comfort and support of

sustained, caring relationships (Menzies 1970; Meleis 1991 and expediency (Holliday 1992).While a managerial ideology has dominated health carefor example). Kitson (1996) has argued that it is this

potential for such relationships that distinguishes nursing practice through the Thatcherite-driven health carereforms, the 1990s have seen a re-emergence of a focusvalues from other care approaches. In a rejection of the

routinized approach to care and in an attempt to claim on ‘humanistic caring’ (Watson 1988; Binnie & Titchen1998; Johns 1994; Ersser 1996) through a ‘person-centred’nursing’s territory, individualized approaches to practice

emerged, with an emphasis on scientific, problem-solving philosophy. At the heart of this style of nursing is thetherapeutic nurse–patient relationship which requires con-and an explicit recognition of the subjective human

experience. This style was attractive to nurses who became tinuity of care and the acceptance of responsibility forthe outcomes of care. It is not surprising that this styleaware of the dehumanizing eCect of the British hospital

system. It oCered a dynamic approach to addressing of nursing has achieved greater acceptance given thedominant health care ideology of consumerism and part-individual patient’s problems with individualized solu-

tions. However, dissatisfaction with the lack of clear lines nership (Jones et al. 1987) and the recognition of aperson-centred philosophy by other professional groupsof accountability and responsibility for decision-making

led to the widespread promotion and development of (Hope 1996; Kitwood 1997).This greater acceptance of person-centred nursing hasprimary nursing (Manthey 1980), most notably in

Manchester, Tameside and Oxfordshire (Alderman 1983; enabled a practice development focus that places greateremphasis on clinical eCectiveness, patient outcomes andBinnie 1987; Wright 1990; Pearson 1992).

These changes were taking place in a health care system evidence-based practice. Nurse-led initiatives, such asnurse-led units, nurse prescribing, and clinical nursethat was dominated by the ideologies of managerialism

with the introduction of ‘general management’ and an specialist roles; and a variety of other independent practiceroles, are examples of how this philosophy is beingincreased emphasis on professionalism. The emphasis was

dominated by the gaining of power and autonomy for articulated. Such initiatives enabled the flourishing ofperson-centred nurses able to think critically, creativelydecision-making. Indeed Porter (1994) argues that the

development of primary nursing was forged largely by a and independently, and who have been able to demon-strate the importance of clinical eCectiveness, evidence-drive among nurses for greater professional autonomy

rather than a desire for more eCective care practices based practice and improved patient outcomes (McKeeet al. 1998; McKenna 1995). However, the current drive(although this rather cynical view is not shared by many

nursing innovators). towards clinical eCectiveness and evidence-based practicehas given rise to the emergence of a plethora of rolesPractice development at this time was predominantly

focused on the development of professional competence concerned with practice development, with little sense ofan overall person-centred purpose or strategic context.for practice (Pearson 1985); the introduction of the nursing

process as a means of articulating care decision-making Indeed, it would appear that the current health careideology has placed greater pressure on clinical nurses to(de la Cuesta 1983); the introduction of systems of quality

assurance, standard setting and clinical audit (McFarlane ‘be seen’ to be doing practice development without asystematic approach or underpinning methodology, stra-1970; RCN 1980; Kendall & Kitson 1986) and the funding

and support of high profile nursing development units tegic direction or individual support.But how does this context inform a contemporary(NDUs) (Salvage & Wright 1995). Nursing knowledge

was expanded through the introduction of nursing models understanding of practice development? While thereappears to be an emphasis on moving towards a person-to underpin individualized care planning and decision-

257© 1999 Blackwell Science Ltd, Journal of Nursing Management, 7, 255–264

B. McCormack et al.

centred style of practice, there has been little evidence of (but interconnected) interfaces in service delivery—client/patient, organizational and strategic interfaces (Fig. 1).an overall co-ordinated approach to developing such

practice, underpinned by a systematic methodology. It is The proposed practice development conceptual frame-work identifies the need for practice development stra-not suggested that there is only one right approach to

‘doing practice development’. However, what is clear is tegies that go beyond the identification of roleresponsibilities of both particular development workersthat staC involved in practice development need to operate

within a framework that recognizes the complexity of and individual nurses. Instead the framework proposesan explicit relationship between the development ofbringing about large-scale organizational change. Kitson

et al. (1996) have argued that in reality the picture is very person-centred practices (which are still often the domi-nant focus of practice developments) and the developmentdiCerent—poorly trained or supported staC are given

practice development and research roles without appro- of an organizational and strategic culture that can supportand sustain such practices. As in the early practicepriate supervision and support and with no strategic view

of what problems to tackle first. A lack of eCectiveness development initiatives in Manchester, Tameside andOxfordshire, many practice changes still appear to relycould be blamed on a lack of understanding of the

processes of managing change in complex organizations on the vision, creativity and charisma of visionary leaders(Walshe & Ham 1997). To counteract this tendency, aand the contextual factors that need to be considered

(Kitson et al. 1998). But is this actually the issue? rigorous framework for the development of practice needsto consider individual, organizational and strategicThe real problem may lie in a lack of understanding

by organizations about their actual development needs. responsibilities for the development of practice and thesustaining of practice changes within the overall organiz-As a result, inappropriate staC are often placed in inappro-

priate positions with a hidden agenda of bringing about ational culture. In addition, it can be seen that practicedevelopment not only involves initiatives which have achange, rather than being specifically designated to work

in particular areas of practice development that is system- direct impact on the care provided to patients, but alsoorganizational developments and strategic planning.atically undertaken. Such work cannot be coercively intro-

duced or indeed introduced by chance. StaC involved in However, a number of enabling factors need to be inplace before such a framework can be operationalized.practice development, practice-based research and the

implementation of research in practice need to be skilled These enabling factors serve to identify the cultural valuesnecessary in the creation of a practice developmentin change processes, research, evaluation techniques and

methodologies, and be confident to use them in specific strategy:$ an understanding of the context and culture of thecontexts.

Kitson et al. (1996) assert: organization$ a commitment to user involvementWhilst it may be unrealistic to expect individuals to

master the range of appropriate methodologies …it may be more feasible to work towards developingteams of research and development personnel withthe range of experience and skill needed to success-fully introduce more clinically eCective patient care.

But even with such preconditions in place, it remainsimportant that an organization has a systematic viewabout the relationship between research and practice andthe place of research in the development of practice; theroles and responsibilities necessary to bring about desireddevelopments; the opportunities available to train keyclinicians in the methodologies and techniques of practicedevelopment and, the support available to developmentworkers.

Towards a conceptual framework

The challenges posed in creating systematic approaches

Organizationalinterface

Learningculture

Strategicinterface

Client/patientinterface

Enablingculture

Patient-centredculture

Reflexiv

e

Ref

lexi

ve

Reflexive

Critical social science

©RCN Institute

to practice development can be seen to demand a concep- Figure 1Conceptual framework for practice developmenttual understanding of development work at three diCerent



$ a recognition of desired practice approaches that are the practice discipline itself—makes a critical social sci-clinically and cost eCective ence philosophy appropriate to practice development$ a culture that fosters a commitment to team develop- approaches that are committed to practitioner ownershipment as a component of clinical eCectiveness of desired changes and organizational recognition of$ recognition that for change to be successful it needs practitioners’ concerns. Adopting a critical social scienceto be practitioner owned, organizationally supported and approach constructs a picture of organizations thatundertaken using a systematic approach exposes prevailing systems that work against the develop-

The overall intention is to develop patient-centred ment of a person-centred approach to practice. Practicepractices that can flourish in an organizational culture development at this level requires a commitment to organ-that recognizes learning as a necessary and explicit compo- izational change, described by Argyris and Schon (1989)nent of professional practice. In addition, the potential as ‘model ii organizational behaviour’. This modelfor practice development to influence strategy develop- emphasizes collaboration, mutual support, critical chal-ment, as well as addressing the implementation of strategic lenge, reflexivity and empowerment of individuals toobjectives, needs to be recognized. Such an approach to change, as illustrated in Fig. 1.the development of practice can be located within a The methodology of critical social science encapsulatescritical social science philosophy and enabled through the the perspectives of all key stakeholders and focuses onprocess of ‘critical companionship’ (Titchen 1998a, b). As establishing methods of data collection that express thewe discuss below, locating practice development within contradictions embedded in the organization, and whichthis philosophy also creates the possibility for the gener- work against a person-centred approach to practice andation of critical social theories about how to transform clinical eCectiveness. In doing so, the organization’s poten-cultures. tial for emancipatory change is enhanced and a clear

direction for the promotion of a development agendaidentified. The following list identifies methods of devel-A critical social science perspectiveopment, education and research that would be appropriate

The development of critical social theory in nursing isat each of the interfaces of the conceptual framework:

often seen as being generated through emancipatory actionDevelopment

research (e.g. Titchen & Binnie 1993; Waterman et al.$ Client/patient interface

1995), guided reflection (Rolfe 1996; Johns 1998) andAttitudinal change

action learning (Fish & Coles 1998; McGill & BeattyConfidence in competence

1998) However, there are other ways of generating knowl-Care processesedge through critical social theory (Stevens 1989, forClinical leadershipexample). Critical social theory concerns itself with criticalInterprofessional relationshipsways of seeing the world and the systems within itNegotiated care(Habermas 1985; Carr & Kemmis 1986; Fay 1987). As

$ Organizational interfacesuch, it accommodates a variety of research and develop-Model II behaviour (Argyris & Schon 1989)ment approaches that enable persons to address constrain-

$ Strategic interfaceing factors that hinder change and creativity. Fay (1987)Strategic planningsuggests that for a social theory to be critical and practical,Political awarenessfirstly there needs to be a recognition of ‘crisis’ in thePopulation profilessocial system and secondly that this crisis is in part caused

Educationby a ‘false consciousness’, i.e. a mismatch between the$ Client/patient interfacereality of practice and the organization’s perception of

Reflective learningthe reality. Interpretation forms the first stage of a criticalWork-based learningsocial science endeavour. This is achieved through theTechnical, aesthetic, empirical, ethical and personalprovision of a systematic critique of participants’ self-knowingunderstanding and social practices. This critique is a

$ Organizational interfaceprerequisite for deciding the most appropriate approachesOrganizational culturesfor changing prevailing power relationships. What FayResearch utilization(1987) suggests is that clarifying the factors that compriseChange theorythe prevailing system of domination, is the first stage of

$ Strategic interfacea critical social science approach. This recognition—theneed to start from the perspective of those engaged with Policy development, utilization and implementation


B. McCormack et al.

Research teristics of openness, supportiveness, approachability,empathetic understanding, reliability, self confidence, and$ Client/patient interface

Evaluation of care inputs the ability to think laterally and non-judgementally. Also,clarity about the role of the critical companion, status,Evidence implementation/utilization

Generation of inductively derived knowledge and intended purpose are vital, as are the skills, knowledgeand style of facilitation. Additionally, the position andTesting of deductively derived knowledge

$ Organizational interface the role of the critical companion in terms of belongingto (local or internal) or being external to (outsider), theEvaluation of organizational systems

$ Strategic interface organization needs to be considered (Heron 1989; Titchen& Binnie 1993; Kitson et al. 1998). Critical companionsInforming public health agendas

The methods identified are not intended to be a defini- bring within them a personal repertoire of skills, as wellas an ability to work within and across role and structuraltive list or indeed a hierarchical ordering of importance.

Instead the education, research and development foci are boundaries in the organization. A critical companion bothuses ‘self’, in a facilitative way parallel to the nurse’sintended to represent appropriate methods which under-

pin a comprehensive practice development framework therapeutic use of self within the nurse–patient relation-ship, and realizes the concepts of critical social scienceand facilitated on both individual and group levels by a

‘critical companion’ (Titchen 1998a, b). (consciousness-raising, problematization, self-reflectionand critique) through a range of practical strategies, suchas critical dialogue and reflective practice.

The role of a critical companion

‘Experience’ is a valuable source of knowledge and recog-nizing the value of nurses’ experience in developing

Example of the framework in usepractice can be an essential route towards increasing ourunderstanding of the nature of practice development. In A 1 year collaborative practice development project

between an NHS trust and the RCN institute wasorder for experience to become learning, there needs tobe a systematic approach in place to assist nurses to instigated in a rehabilitation ward for older people. The

aim of the project was to explore the role nurses’ play inreflect on practice experience, critically review theelements of that practice, actively engage in developing/ rehabilitation, set within a case management framework,

and to measure whether registered nurses as leaders (caseexperimenting with practice and synthesizing the learninggained from the process. Nurses are adult learners, and managers) of the multidisciplinary team improve the

quality of patient care.adult learning theory argues that learning is most eCectivewhen the learner is able to make sense of new knowledge The first stage of the project was to undertake a

literature review to explore what other work had beenin the context of their immediate life experience (Jarvis1983; Schon 1991). The personal and professional chal- done in this area, and to evaluate how this work compared

with practice on the ward. In parallel with this, a ‘battery’lenges associated with engaging in such work and inclarifying values and critically challenging practice are of evaluation methods were implemented to evaluate the

quality of care delivery on the ward, and to gain thegreat and it is easy to underestimate the amount ofsupport that nurses need to meet those challenges. views of the multidisciplinary team about team leadership

and case management.Recognizing this need, Titchen (1998a, b) developed anapproach to the facilitation of learning, in the context of The analysis of the baseline data showed that the

culture of the ward was based on a custodial approachpractice, by a ‘critical companion’ who accompanieslearners on their learning journeys. A critical companion to patient care with a focus on routinized and ritualistic

practice with patients playing a passive role. To compoundfacilitates personal and professional growth, maturity andempowerment; theoretical and practical understanding these problems the results highlighted a lack of eCective

clinical leadership from registered nurses, who did notthrough critique of practice and its contexts; knowledgegeneration from practice and the transformation of prac- fully understand their role or the rehabilitation needs of

older people. It was clear that there was much work totice cultures.In the context of practice development, the critical be done with the nursing team before a case management

approach could be considered, in particular to developcompanion’s job is to help individuals understand whatthey want or need to change and how they could change an active rehabilitation philosophy.

An action research approach was adopted using pre-it to achieve transformation of practice. The facilitationof another’s understanding, requires the personal charac- and post-test evaluation methods. A comparison ward



was used to compare the impact on clinical practice of and rituals, a movement away from a focus on themeeting of physical needs only to a patient-centredthe change strategies used.

For the success of the development activities, it was approach based on holistic and individualized care. Thenurses demonstrated an understanding of the needs ofessential for the nurses to gain ownership of the change

process. To achieve this, the first part of the development older people by rejecting stereotyping and the labelling ofolder patients. Further, the registered nurses had devel-strategy focused on the creation of an active rehabilitation

philosophy which enabled the nurses and members of the oped the ability to reflect on their practice, which hadincreased their confidence as clinical leaders, thus improv-multidisciplinary team to begin to question their own

attitudes, beliefs and values and to begin to challenge ing the overall leadership of the ward. However, the post-evaluation data also highlighted key recommendations forclinical practice.

The second part of the change process was aimed at further development. As a result of this project, the wardteam were in a much better position to develop a caseimplementing cultural and structural changes agreed by

the multidisciplinary team, supported by research evi- management approach to patient care, incorporating thedevelopment needs identified within the post evaluationdence, to establish new norms of clinical practice and

leadership (Fig. 2). data.The comparison ward remained in a static position,The facilitation style of the critical companion in this

case was initially highly directive, with a high educational delivering poor quality patient care which did not meetthe needs of older patients. It was clear that there was aninput through action learning; reflective problem solving

and role modelling. The external facilitator, as critical urgent need to undertake development within this wardto improve the quality of care delivered. It was identifiedcompanion, worked with staC 1 day per month for 12

months. During this time the ward sister was trained to that a similar co-ordinated practice development pro-gramme was needed in the comparison ward and thebe the local or internal facilitator and became a critical

companion to other key members of staC. She reinforced hospital as an organization, to develop the overall qualityof practice. In addition, the results of the project werethe messages on a daily basis. The range of methods used

during this period were individual and group supervision used to inform strategic decisions about the ongoingdevelopment of the service and future purchasing plans.of practice, ward away days, role modelling and role set

development groups. During this period the facilitator’srole changed from external facilitator being directive, to

Key issues in operationalizing the practiceworking collaboratively with an internal or local facilit-

development conceptual frameworkator who developed the skills of successful practicedevelopment. Today most health care providers have a business strategy

in place, detailing the nature of the work and the futurePost-evaluation data demonstrated that the ward haddeveloped an active rehabilitation philosophy. This was aspirations of the organization. Such a strategy should

detail the target areas of development and the qualitydemonstrated through the absence of dominant routinesfeatures that are critical to the organization’s success.Practice development objectives need to be clearly statedand described. Without such an approach, there will beno corporate vision for the organization’s developmentwithin which individual practice developments can takeplace, or no systematic way of collecting evidence ofpractice-influencing policy. By taking such an approach,successful partnerships between academic research anddevelopment units and practice areas can be created.Successful partnerships between such units rely on acommitment to practitioner-‘owned’ development workand the adoption of methodologies that enable prac-titioners to become empowered to act, manifested bycritically challenging prevailing practice ideologies.

What is the driving force behind the developmentinitiative? Whose ideas are being implemented? Is the aim

Strategic interface:enabling culture

Service configurations; roledefinitions; influencing localhealth policy

Organizational interface:learning culture/clinicalleadership

Action learning sets; specificprojects; team building;multiple methods of evaluation

Patient interface: developingpatient-centred rehabilitation

Practice competence; attitudinalchange; role-sets; role modelling;contracted learning; evidence utilization;multiple methods of evaluation

©RCN Institute

to introduce the change in one ward, one department,Figure 2Practice development example across disciplines or across a series of departments or


B. McCormack et al.

directorates? The success of much nursing development companions to possess all of these skills, an organizationneeds to be clear about the specific skills required to bringhas been the ‘individual innovators’ who had a vision and

created the means to turn that vision into a reality. about particular developments and create appropriatepartnerships to achieve them. If the nursing profession isStrategic development plans should not reverse the eCects

of such innovation, but instead it should be supported by to gain a greater understanding of the processes involvedin successfully managing development work, then we needestablishing structural and procedural support to secure

the innovation. Such development work is predominantly practitioners who are committed to and skilled inreflecting on the processes of developing practice. Byfocused on bringing about cultural change. That is,

bringing about changes in the behaviours, actions, lan- making such a process more explicit, individuals can behelped to formalize and systematize what they see aroundguage, customs and attitudes that are taken for granted.

Culture constructs and controls how people perceive the them, how they analyse events and how they both takeaction to improve the situation and move on to makeworld and how they act, but it does so without people

being aware of its influence. People produce and reproduce broader interpretations regarding the underlying knowl-edge underpinning their practice.the culture in their everyday acts (Bennis 1998). Hence,

Bate (1994) argues that the only way to change culture isthrough thinking and acting culturally in our relation-

Summary and conclusionsships. Irrespective of the source of the change, all develop-ment work requires the establishment of a clear project This paper has identified what practice development ‘is’

through the development of a conceptual model based onprotocol with realistic objectives, time frames and evalu-ation techniques. Without such a framework, the change our combined experiences. Our experiences suggest that

in many cases the adoption of a framework such as thiswill only ever be tentative and fragile.As already stated, there is a widespread view that is largely tentative in many practice development pro-

grammes. The importance of practice development beingpractice development work does not require to be under-taken rigorously or systematically and thus managers secured within an organizational culture and underpinned

by strategic planning is emphasized. Traditionally theunderstandably are reluctant to invest in more costlydevelopment programmes that do follow rigorous meth- relationship between practice settings and academic insti-

tutions has been that the latter generate knowledge to beodologies (Kitson et al. 1996). This is further perpetuatedby an attitude that implies that anybody can do develop- applied by the former to improve practice. The adoption

of the proposed conceptual framework oCers a vision forment work and that no specific training or qualificationsare required. Our combined experience is the very the amalgam of knowledge generation and practice

improvements. The creation of partnerships between suchopposite. Ward et al. (1998) identified the problems thatcan arise should change agents not have the necessary institutions, located within the philosophies of critical

social science and critical companionship, creates oppor-knowledge, skills, experience and authority to bring aboutlarge-scale organizational change, whilst Kitson et al. tunities for the generation of knowledge through practice

development. In this approach, academic institutions(1996) have identified a range of skills and knowledgenecessary for developing practice. In addition to the become ‘critical companions’ of service providers, serving

to assist with the identification of practice developmentpersonal characteristics described earlier, facilitators ofchange/critical companions require skills and knowledge targets in business strategies; enabling and facilitating

cultural change to sustain transformational learning andconcerning:$ clinical practice supporting the generation of knowledge through develop-

ment work with the subsequent development of skills and$ researchconfidence.$ change management

This paper represents progress so far in conceptualizing$ problem solvinga framework for practice development. This work is in$ organizational analysis techniquesno way complete. A number of projects are underway to$ interpersonal behaviourfurther define and refine the framework and test its$ decision makingfeasibility.$ facilitation skills

$ organizational culture$ power and influence

References$ visioning techniques

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Documents

Towards practice development — a vision in reality or a reality without vision?