2. The ROYAL HOSPITALS Knowledge Utilisation and Transfer and the Organisation Professor Brendan McCormack, Director of Nursing Research & Practice Development

3. The ROYAL HOSPITALS Presentation Focus Background InfluencesBackground Influences Cultural PerspectivesCultural Perspectives A Strategic FocusA Strategic Focus

4. The ROYAL HOSPITALS Influence 1 - Health & Social Care Policy Centralisation and standardisationCentralisation and standardisation Integrated care delivery modelsIntegrated care delivery models Focus on outcomes and effectivenessFocus on outcomes and effectiveness Customer drivenCustomer driven

5. The ROYAL HOSPITALS Clinical governance and accountabilityClinical governance and accountability Regulation of the professionsRegulation of the professions Competence and performanceCompetence and performance Development of ‘new’ rolesDevelopment of ‘new’ roles Multidisciplinary developmentsMultidisciplinary developments Outcomes and EffectivenessOutcomes and Effectiveness Influence 2 - Professionals

6. The ROYAL HOSPITALS Person-centrednessPerson-centredness PartnershipPartnership CollaborationCollaboration Evidence-basedEvidence-based Community involvementCommunity involvement Influence 3 - Ideologies

7. The ROYAL HOSPITALS Challenges of working with these influences The pace of changeThe pace of change Rhetoric of effectiveness versus reality of practice culturesRhetoric of effectiveness versus reality of practice cultures Changing political [P & p] climatesChanging political [P & p] climates Fear of the publicFear of the public Confidence in competenceConfidence in competence Debunking of old norms and stereotypes!Debunking of old norms and stereotypes!

8. The ROYAL HOSPITALS Research and Knowledge Utilisation in a Segmented Culture Hierarchical managementHierarchical management Research done by academicsResearch done by academics Evidence is unimportant to practiceEvidence is unimportant to practice Knowing the evidence versus the realities of practiceKnowing the evidence versus the realities of practice Poor research and PD infrastructurePoor research and PD infrastructure Significant recruitment and retention problemsSignificant recruitment and retention problems No facilities to support reflective practitioner inquiryNo facilities to support reflective practitioner inquiry

9. The ROYAL HOSPITALS Developing Critical Inquiry  Practice is messy, complex & enmeshed in ethical conflict (Schon, 1991).  Practice is embedded in multiple cultures – “work-place culture” (Manley, 2000).  Accessing work-place cultures enables the release of practice knowledge that is embedded in experience (Titchen & Higgs, 2001).  Deductive & inductive knowledge equally valued (Kitson et al, 1998)  The primary intention of becoming critical is ‘increased effectiveness in patient-centred care’ (Garbett & McCormack, 2002)  Getting research into an organisation requires individual, organisational and strategic directions (McCormack et al, 1998)

10. The ROYAL HOSPITALS Research in an Inquiring Culture  Shared governance approach to management  Quality is everybody’s business  Patient-centred approach to practice  Reflective feedback from patients  Practitioner participation in evidence generation and utilisation  Ward leader as practice developer  Supported reflective processes  Systematic evaluation of achievements

11. The ROYAL HOSPITALS Strong and Effective Cultures have ……….. People valuesPeople values Emphasis on internal communication and respect for all employees at all levelsEmphasis on internal communication and respect for all employees at all levels Shared values and practicesShared values and practices A shared common purpose and the means of achieving itA shared common purpose and the means of achieving it

12. The ROYAL HOSPITALS High levels of employee motivation through participation and rewardHigh levels of employee motivation through participation and reward Learning from the pastLearning from the past Adapt to changeAdapt to change Are strategically appropriateAre strategically appropriate Value large stakeholders (especially employees)Value large stakeholders (especially employees) Value effective leadership at all levels (transformational leadership)Value effective leadership at all levels (transformational leadership)

13. The ROYAL HOSPITALS How is it Achieved?  Every aspect of nursing and its organisation is practice focused.  Central focus on the development of expertise.  Organisational support to enable practitioner inquiry – “no wing clipping”.  Criticism is not suppressed – “not a harmonious team”.  Encouragement for “self-evaluation”.  Development of transformational leaders.  Focus on processes rather than on changing structures.  External knowledge is welcomed and valued

14. The ROYAL HOSPITALS “We have to shift the centre of gravity in our philosophical tradition, and to alter our established mode of thinking. To propose this is easy; to accomplish it is so difficult that complete success at the first attempt is inconceivable. We are largely creatures of habit; not least in our reflective activities. To change our standpoint is to transform our habits of thought. It is not to exchange one theory for another, but to change the basis of all theory” (McMurray, 1991; 85 – The Self as Agent)

15. The ROYAL HOSPITALS Develop Research and Practice Development Knowledge and Expertise. Practice Development Clinical Education Org. Development Develop the research and practice development infrastructure Developing practices and the context to support an expert person-centred inquiring culture Research Undertake and Utilise Research in Key Clinical Themes identified by practitioners Knowledge Generation Patient- centred Practices

16. The ROYAL HOSPITALS Knowledge for Practice Professional Knowledge as:Professional Knowledge as:  Scientific knowledge  Competence  Public knowledge  Craft knowledge

17. The ROYAL HOSPITALS Frameworks embedded in the Royal Hospitals Approach to knowledge generation, implementation and utilisation Practitioner ResearchPractitioner Research Practice DevelopmentPractice Development The PARiHS FrameworkThe PARiHS Framework Creating a Learning EnvironmentCreating a Learning Environment

18. The ROYAL HOSPITALS 1. Practitioner Research “practitioner research is a formal and systematic attempt made by practitioners alone, or in collaboration with others, to understand practitioners work, with the intended purpose of transforming self, colleagues and work contexts and the development of new understandings of practitioners’ work” [adapted from Brooker & MacPherson, 1999) Level 1: Practitioner LedLevel 1: Practitioner Led Level 2: Practitioner CollaborativeLevel 2: Practitioner Collaborative Level 3: Practitioner FocusedLevel 3: Practitioner Focused

19. The ROYAL HOSPITALS 2. Practice Development Practice development is a continuous process of improvement towards increased effectiveness in patient centred care. This is brought about by enabling health care teams to develop their knowledge and skills and to transform the culture and context of care. It is enabled and supported by facilitators committed to systematic, rigorous continuous processes of emancipatory change that reflect the perspectives of service users and service providers (Garbett & McCormack, 2002)

20. The ROYAL HOSPITALS Improving patient care Learning in and from practice Systematic approaches Values clarification; visioning workshop; fantasy writing Pre-post evaluation; discussion groups; cultures workshop Action Planning and Review of Progress; integral data collection Action learning; work-based learning; reflective practice (Garbett & McCormack, 2002)

21. The ROYAL HOSPITALS 3. The PARiHS Framework Successful implementation of evidence is a function of the relation between: the nature of the evidence the context or environment in which the proposed change is to be implemented and, the way or method by which the change is facilitated SI= f(E,C,F) [Kitson et al, 1998; 2002]

22. The ROYAL HOSPITALS Understanding the importance of the development of the practice and organisational context (McCormack et al, 2002)Understanding the importance of the development of the practice and organisational context (McCormack et al, 2002) Development of facilitation roles and relationships (Harvey et al, 2002)Development of facilitation roles and relationships (Harvey et al, 2002) Embracing a variety of forms of evidence and integrating them into practice development, practitioner research and quality improvement agendas (Kitson et al, 1998)Embracing a variety of forms of evidence and integrating them into practice development, practitioner research and quality improvement agendas (Kitson et al, 1998)

23. The ROYAL HOSPITALS 4. Creating a learning environment Improve the knowledge base among staff at all levels in terms of: Identifying appropriate questions for ‘new’ research and distinguishing between the need for new research versus the implementation of existing knowledge.Identifying appropriate questions for ‘new’ research and distinguishing between the need for new research versus the implementation of existing knowledge. Research methodologies.Research methodologies. Practice development frameworks and processes.Practice development frameworks and processes. Data collection, analysis and dissemination processes.Data collection, analysis and dissemination processes. The use of systematic approaches to audit and evaluation in order to transfer knowledge into practice.The use of systematic approaches to audit and evaluation in order to transfer knowledge into practice. Reading research critically and understanding how to make judicious use of research in practice.Reading research critically and understanding how to make judicious use of research in practice.

24. The ROYAL HOSPITALS Develop staff knowledge in approaches to developing a culture of ‘critical inquiry’ in practice settings: Increase awareness of approaches to reflective practice.Increase awareness of approaches to reflective practice. Develop an understanding of the way knowledge can be generated from practice as a legitimate research activity in itself.Develop an understanding of the way knowledge can be generated from practice as a legitimate research activity in itself. Expose staff to models of critical inquiry.Expose staff to models of critical inquiry. Help clinical leaders identify the readiness of their practice context for critical inquiry.Help clinical leaders identify the readiness of their practice context for critical inquiry.

25. The ROYAL HOSPITALS "The reasonable man adapts himself to the world; the unreasonable man persists in trying to adapt the world to himself. Therefore, all progress depends on the unreasonable man” [George Bernard Shaw, 1856-1950]