Firstly, it is necessary to give a few core definitions to the topic and put in into it into a context. Practice development (PD) has been widely defined by many authors and professionals. Following it is possible to finda selection of some of the most accurate and well-known definitions.
Firstly, Joyce (1999, p. 109) defines Practice Development as the implementation of ‘initiatives that promote change or maintain good practice in order to enhance care’. The latter is undoubtedly a very concise definition. Further extended definitions were provided by, in example, McCormack et al (2004), who consider practice development as a continuous process of improvement in order to increase effectiveness in patient-centered care ‘through the enable of nurses and health care teams to transform the culture and context of care’. Simmons (2003, p. 37) argues that practice development is in fact supported by a series of ‘facilitators’ committed to a ‘systematic, rigorous, continuous process of emancipatory change’ (Simmons, 2003, p. 37).
The latter statement refers to ’emancipatory practice development’, one of the two approaches to PD, together with technical practice development, and which has lately been joined by a third type: transformational Practice Development (Dewing, 2008, p. 134)
Definitions and studies on Practice development are, obviously also addressed to maximize quality and benefits of nursing PD. Clarke and Wilcockson (2001, p. 264) stated that the main issues to be considered in the changes and characteristics of the context of nursing care are: the influence of PD in the learning of the staff in the health organisation and the ‘robustness of the evidence upon which the development is based ‘.
Practice development in patient care must also be encouraged and directed in order to have a forwarding vision and to guess how and what the service and initiatives must look like, always eliminating boundaries, or at least challenging them (Clarke and Wilcockson, 2002, p. 406).
It is important to note that, in practice development, organisation and professional learning should never develop independently. Since the organisation must be a learning place, it is necessary to classify the achievable types of knowledge (Clarke and Wilcockson, 2001, p. 264). Depending on the author it is possible to find different classifications of such knowledge. In fact, according to Clarke and Wilcockson (2002, p. 398) knowledge can be: distal or proximal. The former is also known as ‘knowledge for practice’ and the latter as knowledge ‘from practice’ (that depends on the contextual issues within the environment like staffing levels). To bring together both knowledges is the most common desire: a synthesis of scientific theoretical, experimental and personal knowledge.
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Concretely in this case, nurses of the health organisation, as professionals, can hold knowledge for the organisation itself and create theories of action and strategies. As a matter of fact to analyse an organization’s knowledge and influence of its practice developments, soft system methodology is used. Such technique approach problems actively and focuses the research on encouraging change rather than just analysing and describing the problem (Clarke and Wilcockson, 2001, p. 265).
As Clarke and Wilcockson (2001, p.399) state, soft system methodology develops ‘models of relevance to the ‘real world’, or practice situation’, in order to achieve greater and more successful changes. The most important part of the system is the analysis of the data recollected since it permits the creation of a general picture about the impact of practice developments within the chosen organisation and on its individuals (Clarke and Wilcockson, 2002, p. 399 – 401).
In recent years it has been created a debate about the application of research-based knowledge and the implementation of evidence-based practice. Its advantages are clear but it also has a few disadvantages including the possible lack of skills in research critique, the lack of interest of the individual to any available written knowledge or the lack of conformity with the evidence (Clarke and Wilcockson, 2002, p. 397). The considered solution to some of the barriers may be to implement and encourage education within the organisation in order to promote individual skills. In the light of this information, the implementation will be successfully achieved when evidence is scientifically firm, when the context is receptive to change with sympathetic cultures, the feedback system works satisfactorily and there is an appropriate monitoring and leadership (Harvey et al, 2002, p. 578). But the most important factor would be the existence of facilitators for the change, which could be external or internal.
Firstly, it is necessary to define the term facilitation. It is a concept emerged from both student-centred learning and counselling, which is influenced by humanistic psychology, as Harvey et al (2002, p. 580) mentioned. It refers to ‘a process of enabling individuals and groups to understand the processes they have to go through to change aspects of their behaviour, or attitudes to themselves, their work or other individuals’ (Marshall and Mclean, 1988). The term has been used in different disciplines, inside and outside the health care field. Therefore, facilitation is the process of encouraging experimental learning through critical reflection, helping organisations and professionals to understand what they need to change and how they should do it in order to achieve the before mentioned evidence-based practice.
A more simplified definition, by Kitson et al (as recollected in Harvey et al, 2002, p. 579) describes facilitation as ‘a technique by which one person makes things easier for others’.
The fact is that in all definitions the term change is included and there are a series of strategies considered to be effective promoting such change like educational outreach visits, audits, feedback and even a marketing approach. Existing practices are challenged and individuals within the organization must embrace new theoretical approaches to improve their practices. It has been proved, that a combination of various approaches is the most effective way of facilitation.
One facilitation model could be the ‘Oxford Model’ of facilitation, created in the first half of the 1980s and which consists in the introduction of more systematic approaches to the prevention of coronary heart diseases and in order to support the creation of more health checks and regular screenings for high-risk patients (Harvey et al, 2002, p. 580).
The facilitation process, then, involves facilitators using a range of interpersonal and group skills to achieve the desired change. Literature shows that facilitation in evidence-based practice development addresses the following issues: facilitating change, evidence translation and communication, responding to external influences and agendas, education and life-long learning, getting research into practice and audit and quality initiatives. (Dewing, 2008, p. 136).
INTENSIVE CARE NURSING
Applying the theory developed before more concretely to the intensive care nursing field, it goes without doubt that nurses can improve patient recovery by using the mentioned before patient -centered care, and, as the Guidance for nurse staffing in critical care (Unknown author, 2003, p. 259) points out by applying ‘pro-active management and vigilance, coping with unpredictable events and providing emotional support’. The effectiveness of the nurses improves with proactive prediction and prevention of any possible complications and ‘prompt and skilled intervention in the event of sudden deterioration’ (Unknown author, 2003, p. 259).
Carroll carried out an study which has several useful applications into the nursing care field. Carroll (1997, p. 210) then, identified seven of the most used facilitators in nursing practice according to the answers of a series of participants. The most frequently cited facilitator was ‘the need to have more time available to review and implement research findings’. The other six cited facilitators were: conducting more clinically focused relevant research, improving availability/accessibility of research reports, enhancing administrative support and encouragement, providing colleagues support networks/mechanisms, advanced education/increasing research knowledge base, improving the understanding of research reports. (Carroll, 1997, table 2) Barriers to the development of advanced practice in nursing include resistance (both active and passive) or the opposition and obstruction of new roles and responsibilities (Srivastava et al, 2008, p. 2674). Other negative factors in the context of nursing care that would act as barriers would include the fact that the personal beliefs of some practitioners may actively promote discriminatory care (which is called, by Clarke and Wilcockson, 2002 ‘corruption of care’) (Clarke and Wilcockson, 2002, p. 397 -398).
In particular, within nursing, the definition of ‘facilitation’ is more closely related to the before stated term of change, and more particularly to the promotion of communication between organizations (Simmons, 2003, p. 42). In the first paragraphs of this essay emancipatory and transformational Practice Development were mentioned. Such concepts have especial focus on facilitation, and as stated before this facilitation has two types, the inside and the outside. However, McCormack et al (2007) have stated that such a division is too simplistic but it is useful when clarifying terms. Outsider or external facilitators involve project planning and learning expertise on nursing discipline (in this case) that may be missing within the organization. Internal facilitators for Project Development, however, have a more direct role in day-today facilitation (Unknown, 2003, p. 259).
Nursing practice development can make a significant contribution to the improvement of patient and service user experiences and to the modernization of intensive care services through its focus on improving workplace cultures and learning. McCormack and Titchen (2006) recommend key policy and strategy stakeholders need to be targeted in order to develop a strategic way forward for connecting practice development methods with service/systems developments, set within a modernization and risk management agenda.
Clearly Nursing Managers can influence this area at various strategic interfaces in the course of their work (Dewing, 2008, p. 139).
To start concluding, the term practice development has been, therefore, used to describe a ‘range of approaches, methods and processes in organising and delivering diverse changes in nursing practice for many years’ (Dewing, 2008, p. 134). Thus there are plenty of evidence who assure that improved outcomes are not just a result of numbers of staff, but are more related to the staff level of training and skills. (Srivastava et al, 2008, p. 2675 -2678)
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Tasks of facilitation and in particular of facilitation in nursing would more concretely include: leading meetings and developing systems and programmes; the assessment and monitoring of care and data collection and the undertaking of joint clinical consultation with practice nurses (Simmons, 2003, p. 45). The facilitator/educator nurse is in charge of providing and locating resources. Therefore, nursing facilitation for practice development must be addressed by a facilitator ‘who provides a focus for nurses to obtain the information they require to pursue a professional or practice development goal (as stated by Thornbory, 1999 and recollected in Simmons, 2003, p. 45). A nurse in that role will be effective if counts on a series of qualities such as: personal confidence, formal education, training and preparation; supervision, feedback from other professionals or organizations, assertiveness and negotiation skills and experience in his/her specialty. It is also important if the nurse facilitator can count on a supportive organizational culture (Srivastava et al, 2008, p. 2674)
What it is undeniable is that facilitation needs of critical thinking. Since facilitation should involve confronting, questioning and critical reflection (as pointed out in Simmons, 2003, p. 44), critical thinking is a key element to enable professionals (and concretely nurses) within an organization to understand the different elements that create a clinical situation.
Nursing facilitation, concretely, will need to count on critical thinking in order to improve nurses’ skills and knowledge. In order to achieve that, a nurse educator with the suitable nursing expertise or practice development nurse must be appointed. New nursing staff in critical care need to easily identify their nurse educator in order to ensure their continued development after the orientation period (Unknown author, 2003, p. 264). This facilitates the learning culture within the organization in ‘which evidence-based practice can be developed to meet the needs of the patients’ (Unknown, 2003, p. 263). As a matter of fact an expert nurse in critical care with highly developed technical skills and supportive knowledge will be helpful in extending the knowledge, and consequently the role of intensive care nurses. The latter is in fact a very controversial topic lately; however it is not the topic of this essay. As an example of facilitation and its practical application it can be say that it can assure advance practice in: ‘cannulation, venepuncture, ordering blood tests and X-rays; performing physiotherapy; inserting arterial lines; performing elective cardioversion; thrombolysis treatment and intubation (Srivastava et al, 2008, p. 2675). As Rutherford et al 2005 (and it was recollected in Sarivastava et al, 2008, p. 2674) assert, the organizational infrastructure is central in encouraging new roles and establish the perfect framework for debate.
Therefore, effectiveness in intensive care nursing includes facilitator skills such as adaptability, prior experience, personal confidence and assertiveness. Training and preparation, feedback from other professionals and a supportive organizational culture are also signaled by Lloyd Jones, 2005 as needed skills (and as it is recollected in Srivastava et al,2008, p. 2675).
A key element for critical thinking and advanced practice in nursing is without any doubt autonomy. Autonomy is defined by Fairley, 2003 (as found in King and MacLeod, 2002, p. 322) with three other terms: (independence, identity and authority) with an additional dimension of self-determination. Expert critical care practitioners in any field will use intuition. In fact King and LcLeod (2002, p. 322) have developed a research on the intuition used by nurses at different levels of practice in decision-making.
Autonomy and intuition are key elements of an effective advanced practice performance.
It is also necessary to note that, as stated before, the debate about the expansion of nursing roles in intensive care in the UK has been created years ago. Before a change like such occurs it is necessary to note that clarity about training, status, authority, career structure and remuneration must be clear.
Nowadays, the context of care in nursing have experimented a series of innovations which profound changes, especially in the field of the working relationships between nurses and medical staff. It is also necessary to note that Intensive Care nursing is a quite new field (which developed into a separate category around 1995, English, 1997) which appeared in order to ensure that patients with an uncomplicated recovery will always be attended. Nowadays, critical care practitioners make all decisions about routine management and over combined roles of anaesthetist, perfusionist and intensivist while carrying on with conventional nursing care. Facilitation and practice development are therefore key issues for intensive care nursing. The implementation of critical care practitioners needed of training and improvement of quality of care merits (English, 1997). Also it needed of three main steps: to give the appropriate title to the nurses depending on the specialist training they received, to give them the necessary authority ‘to act independently, commensurate with the responsibility that they already carried’ and changes in the salary which, allegedly reflect the value of the work and helped retaining the staff. In English’s (1997) words: ‘Trusts now have more freedom to set appropriate terms and conditions of service for staff, but support is also needed from the nursing authorities and the Department of Health’.
Concluding, it is noticeable that there is a clearly positive relationship between research utilization and attitude toward that research, the extended use of professional nursing journals among clinical nurse educators and higher levels of education. In fact, despite the fact that not all intensive care practitioners have the necessary critical approaches and skills (and evidence-based practice research) to use research effectively in practice, such new field like critical care nursing is evolving in the good directions thanks to the use of those facilitators among other factors.
The latter affirmation is based on some studies that have been lately developing a deeper approach into clinical nurse educators and the determinants of their research utilization behaviour in clinical practice.
Furthermore, it is necessary to point out that it is necessary further research and improvements in the field, especially research on the outcomes of research utilization, including the effectiveness of their role as educators/facilitators and the organization and, over all, contexts in which they practice.
Finally, the Royal College of Nursing (RCN) standards on effective workplace culture are going to be used in order to clarify which vital areas need to be encouraged for an effective culture: the need of developing person-centeredness, also ‘developing individual, team and service effectiveness, developing evidence-based health care including knowledge of utilization, transfer and evidence development and developing an effective workplace culture’ (Dewing, 2008, p. 136).
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