‘Enabling person-centred practice within HSE West: an emancipatory practice development approach’

Dr Randal ParlourAssistant Director NMPD (HSE West)Honorary Fellow (University of Ulster)

• Practice development is a continuous process of developing person-centred cultures

• It is enabled by facilitators who authentically engage with individuals and teams to blend personal qualities and creative imagination with practice skills and practice wisdom

• The learning that occurs brings about transformations of individual and team practices. This is sustained by embedding both processes and outcomes in corporate strategy.

(McCormack, Manley & Wilson, 2008)

Person-centred care is a fundamental tenet in key national documents:

• National Standards for Safer Better Healthcare (HIQA (2012)

• Future Health: A Strategic Framework for Reform of the Health Service

(HSE 2012)

A Review of Practice Development in Nursing & Midwifery in the Republic of Ireland & Development of a Strategic

Framework (2010)

• identified how practice development can provide a sustainable methodology to transform the culture and context of care within Ireland to deliver real person-centred care cultures within the context of national health policy.

• identifies the importance of multidisciplinary activity in supporting the development of person-centred practice cultures

• evidence presented recommends the need to develop facilitation and work-based learning expertise and infrastructures within the Irish health system.

• is about delivering person centred, safe and effective health care by developing people and their practice.

Collaborative Research & Development

• Introductory Practice Development Schools

• Developing Practice with Older People

• Productive Ward/Releasing Time to Care

• Nursing & Midwifery Metrics

The principles of collaboration, inclusion & participation underpin approaches to PD research and development and guide ways of

working with participants & stakeholders

The aims of the school are - • to provide an opportunity for

participants to focus on their own effectiveness in fostering a culture of learning that is person-centred;

• to explore the evidence base to practice development in relation to their own learning;

• and, experience the process of effective teamwork and group learning in relation to practice development concepts and theory.

Introductory Practice Development Schools

Outcomes• Support the initial development of key individuals to lead out on

culture change in Health Service Executive (HSE) organisations, supported and enabled by senior management within each organisation.

• Evaluation confirms the effectiveness of these schools especially when run in conjunction with senior management support for Practice Development and national/local Practice Development strategy

• Significant in building capacity within the health system and in developing a critical mass of ‘champions’ to support the changes required

• ‘In practice there is time if we as a team agree on how that time is best used to achieve a person centred service for patients and staff.

• ‘I had thought that PD was about someone or some department, I now realise that we are all PD people and can become involved in changes to enhance care’

• ‘I came here with an open mind willing to learn all I could, I found the whole experience very enlightening, empowering and thought provoking

• ‘Everyone has a part to play in the development of practice, it is something I am responsible for’.

Developing Practice with Older PeopleNMPD facilitators challenge & support internal facilitators and

healthcare teams -• to get beneath the surface of daily routine• to critically reflect on the values and beliefs they hold about patient

care • to identify what needs to change and the part they need to play in

effecting improvement• to consider if team behaviours, systems and processes used in

practice, are consistent with person centred values.

This is the essence of caring and is dependent on staff who create the climate and culture within which patients are cared for.

Parlour & McCormack 2012

Developing a culture of effectivenessManley, Parlour & Yalden (2013)

START END

PRACTICAL STRATEGIES Build a shared vision for practice direction &

ways of working Raise awareness of the context & culture of care

& its impact using quantitative & qualitative inquiry methods to evaluate practice, collaboratively gather data from observations of care, other tools, patient experience, literature reviews.

Identify stakeholder claims, concerns & issues & act on these

Provide feedback & engage staff in making sense of data & observations through multi-professional critical reflection, critical dialogue, to enable the identification of specific baseline contexts

Facilitate group processes/action/active learning with an ethic of valuing contributions from all members; challenge & support, sharing critical incidents on own practice & practice context & implementing shared values within a safe environment

Enable collaborative participation in action cycles, action plans, implementation & evaluation

Recognise & celebrate achievements Use Qualitative 360 feedback to enable

practitioners to give & receive feedback, build effective relationships, & develop role clarity

Source of evidence Source of evidence

An effective workplace cultureUnreceptive/

under-developed culture

• Individual/team learning & sharing

• Awareness of facilitator role

• Collaborative analysis

• Staff less isolated/increased confidence• Improved patient

care• Achievement of

purpose/objectives• Ongoing learning

& changes to practice

• Innovation• Transformed

cultures & contexts

• No shared vision• Lack of

coherence/teamwork• No explicit values

guiding practice• Unclear roles &

responsibilities• Inconsistent

standards• Little use of critical

reflection & workplace learning

• Team members feeling isolated

• Little/no evaluation of practice culture

Productive Ward/Releasing Time to CareSpecific objectives :

• To examine how the PW initiative facilitates the development of person-centred workplace cultures for staff.

• To examine how the PW initiative improves the experiences of patients and their families

McCormack & McCance (2010)

Measurable Outcomes• Satisfaction with care• Involvement with care• Felling of well being • Creation of a therapeutic culture

McCormack & McCance (2010)

Instrumentation - StaffContext Assessment Index (range 1-4) - Assists practitioners in assessing & understanding the context in which they work

• Person-centred Practice Index (range 1-5) – measures the extent to which staff rate their work setting to be person-centred

• Instrumentation - Patients• Person-centred Climate Questionnaire – Patients (range 17-119)

Evaluates to what extent the climate of health care settings are perceived by patients as being person-centred Evaluates to what extent the climate of health care settings are perceived by patients as being person-centred

• Patient Experience Questionnaire (range 0-100) - systematically gathers the views of patients about the care they have recently received

ResultsSite Prerequisites The Care

EnvironmentCare Processes

The Patient Experience Questionnaire

The Person-centred Climate Questionnaire.

5 4.5 4.1 4.6 90.3 109.61 4.2 3.8 4.0 85.7 106.2

6 4.3 3.8 4.4 73.0 106.0

2 4.3 3.9 4.3 82.4 104.4

4 4.2 3.9 4.2 83.2 103.8

3 4.3 3.8 4.2 84.6 103.0

           TOTAL 4.3 3.9 4.3 84.5 105.6

Nursing & Midwifery Metrics

• The RCN (2009) explicate the role of nursing & midwifery in improving care outcomes for patients and clients

• These three elements provided the scope for this evaluation and

were central to the subsequent evaluation design.

Objectives• Investigate the impact of the ‘Medication Management Metrics’ in

regards to safe and effective care.

• Examine the experiences of patients with a specific focus on how their nursing care needs are met.

• Examine the experiences of staff with regard to the implementation of this initiative within the workplace.

• To create a deeper understanding of how the ‘Metrics’ initiative impacts upon the context within which care is delivered.

• Clarify the links between this initiative and other strategic/organisational priorities.

Study Outcomes

Nursing Staff – Quantitative Findings

• Independent pre-post test design

• No or inconsistent impact on workplace culture as measured using the Nursing Context Index and Context Assessment Index

• Slight impact on nurse stress levels but inconsistent pattern of change across locations

Nursing Staff – Qualitative Findings

• Cascade method of knowledge transfer

• Lack of reach to staff nurses resulting in: Piecemeal implementation A lack of engagement by staff nurses Poor understanding of the study aims Lack of ownership at staff nurse level Poor engagement with other health care staff (eg Medical

Clinicians)

Patient findings

• Overall the Medication Management Metrics intervention had, at best, a slight improvement, on patients’ perceptions of person-centred care

• Marginal increase in scores but not at a statistically significant level

Thank You For Listening

randal.parlour@hse.ie