The ROYAL

HOSPITALS

Knowledge Utilisation and Knowledge Utilisation and Transfer and the OrganisationTransfer and the Organisation

Professor Brendan McCormack, Professor Brendan McCormack,

Director of Nursing Research & Director of Nursing Research & Practice DevelopmentPractice Development

The ROYAL

HOSPITALS

Presentation FocusPresentation Focus

• Background InfluencesBackground Influences

• Cultural PerspectivesCultural Perspectives

• A Strategic FocusA Strategic Focus

The ROYAL

HOSPITALS

Influence 1 - Health & Social Care PolicyInfluence 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

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 - ProfessionalsInfluence 2 - Professionals

The ROYAL

HOSPITALS

• Person-centrednessPerson-centredness

• PartnershipPartnership

• CollaborationCollaboration

• Evidence-basedEvidence-based

• Community involvementCommunity involvement

Influence 3 - IdeologiesInfluence 3 - Ideologies

The ROYAL

HOSPITALS

Challenges of working with these Challenges of working with these influencesinfluences

• The pace of changeThe pace of change

• Rhetoric of effectiveness versus reality of Rhetoric of effectiveness versus reality of practice culturespractice 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!

The ROYAL

HOSPITALS

Research and Knowledge Utilisation in a Research and Knowledge Utilisation in a Segmented CultureSegmented 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

The ROYAL

HOSPITALSDeveloping Critical InquiryDeveloping Critical Inquiry

Practice is messy, complex & enmeshed in ethical conflict Practice is messy, complex & enmeshed in ethical conflict (Schon, (Schon, 1991).1991).

Practice is embedded in multiple cultures – “work-place culture” Practice is embedded in multiple cultures – “work-place culture” (Manley, 2000).(Manley, 2000).

Accessing work-place cultures enables the release of practice Accessing work-place cultures enables the release of practice knowledge that is embedded in experience knowledge that is embedded in experience (Titchen & Higgs, 2001).(Titchen & Higgs, 2001).

Deductive & inductive knowledge equally valued (Kitson Deductive & inductive knowledge equally valued (Kitson et alet al, 1998), 1998) The primary intention of becoming critical is ‘increased The primary intention of becoming critical is ‘increased

effectiveness in patient-centred care’ effectiveness in patient-centred care’ (Garbett & McCormack, 2002)(Garbett & McCormack, 2002) Getting research into an organisation requires individual, Getting research into an organisation requires individual,

organisational and strategic directions organisational and strategic directions (McCormack et al, 1998)(McCormack et al, 1998)

The ROYAL

HOSPITALS

Research in an Inquiring CultureResearch in an Inquiring Culture

Shared governance approach to managementShared governance approach to management Quality is everybody’s businessQuality is everybody’s business Patient-centred approach to practicePatient-centred approach to practice Reflective feedback from patientsReflective feedback from patients Practitioner participation in evidence generation and Practitioner participation in evidence generation and

utilisationutilisation Ward leader as practice developerWard leader as practice developer Supported reflective processesSupported reflective processes Systematic evaluation of achievementsSystematic evaluation of achievements

The ROYAL

HOSPITALS

Strong and Effective Cultures Strong and Effective Cultures have ……….. have ………..

• People valuesPeople values

• Emphasis on internal communication and Emphasis on internal communication and respect for all employees at all levelsrespect for all employees at all levels

• Shared values and practicesShared values and practices

• A shared common purpose and the means of A shared common purpose and the means of achieving it achieving it

The ROYAL

HOSPITALS

• High levels of employee motivation through High levels of employee motivation through participation and rewardparticipation and reward

• Learning from the pastLearning from the past• Adapt to changeAdapt to change• Are strategically appropriateAre strategically appropriate• Value large stakeholders (especially Value large stakeholders (especially

employees)employees)• Value effective leadership at all levels Value effective leadership at all levels

(transformational leadership)(transformational leadership)

The ROYAL

HOSPITALS

How is it Achieved?How is it Achieved? Every aspect of nursing and its organisation is practice Every aspect of nursing and its organisation is practice

focused.focused. Central focus on the development of expertise.Central focus on the development of expertise. Organisational support to enable practitioner inquiry – Organisational support to enable practitioner inquiry –

“no wing clipping”.“no wing clipping”. Criticism is not suppressed – “not a harmonious team”.Criticism is not suppressed – “not a harmonious team”. Encouragement for “self-evaluation”.Encouragement for “self-evaluation”. Development of transformational leaders.Development of transformational leaders. Focus on processes rather than on changing structures.Focus on processes rather than on changing structures. External knowledge is welcomed and valuedExternal knowledge is welcomed and valued

The ROYAL

HOSPITALS

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

The ROYAL

HOSPITALS

Develop Research and Practice Development Knowledge and Expertise.

Practice DevelopmentClinical E

ducation

Org. DevelopmentDevelop 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

Genera

tion

Knowledge

Generation

Knowledge

Generation

Knowledge

Genera

tion

Patient-centred

Practices

The ROYAL

HOSPITALS

Knowledge for PracticeKnowledge for Practice

• Professional Knowledge as:Professional Knowledge as: Scientific knowledgeScientific knowledge CompetenceCompetence Public knowledgePublic knowledge Craft knowledgeCraft knowledge

The ROYAL

HOSPITALS

Frameworks embedded in the Frameworks embedded in the Royal Hospitals Approach to Royal Hospitals Approach to

knowledge generation, knowledge generation, implementation and utilisationimplementation and utilisation

• Practitioner ResearchPractitioner Research

• Practice DevelopmentPractice Development

• The PARiHS FrameworkThe PARiHS Framework

• Creating a Learning EnvironmentCreating a Learning Environment

The ROYAL

HOSPITALS

1. Practitioner Research1. Practitioner Research““practitioner research is a formal and systematic attempt practitioner research is a formal and systematic attempt

made by practitioners alone, or in collaboration with made by practitioners alone, or in collaboration with others, to understand practitioners work, with the others, to understand practitioners work, with the intended purpose of transforming self, colleagues and intended purpose of transforming self, colleagues and work contexts and the development of new work contexts and the development of new understandings of practitioners’ work” understandings of practitioners’ work” [adapted from [adapted from Brooker & MacPherson, 1999)Brooker & MacPherson, 1999)

• Level 1: Practitioner LedLevel 1: Practitioner Led• Level 2: Practitioner CollaborativeLevel 2: Practitioner Collaborative• Level 3: Practitioner FocusedLevel 3: Practitioner Focused

The ROYAL

HOSPITALS

2. Practice Development2. Practice DevelopmentPractice development is a continuous process of Practice development is a continuous process of improvement towards improvement towards increased effectiveness in increased effectiveness in patient centred care.patient centred care. This is brought about by This is brought about by enabling health care teams to enabling health care teams to develop their develop their knowledge and skills and to transform the knowledge and skills and to transform the culture and context of care.culture and context of care. It is enabled and It is enabled and supported by facilitators committed to supported by facilitators committed to systematic, rigorous continuous processessystematic, rigorous continuous processes of of emancipatory change that reflect the emancipatory change that reflect the perspectives perspectives of service users and service providersof service users and service providers(Garbett & McCormack, 2002)

The ROYAL

HOSPITALS

Improving patient care

Learning in

and fr

om

practic

e

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)

The ROYAL

HOSPITALS

3. The PARiHS Framework3. 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]

The ROYAL

HOSPITALS

• Understanding the importance of the Understanding the importance of the development of the practice and organisational development of the practice and organisational context (McCormack et al, 2002)context (McCormack et al, 2002)

• Development of facilitation roles and Development of facilitation roles and relationships (Harvey et al, 2002)relationships (Harvey et al, 2002)

• Embracing a variety of forms of evidence and Embracing a variety of forms of evidence and integrating them into practice development, integrating them into practice development, practitioner research and quality improvement practitioner research and quality improvement agendas (Kitson et al, 1998)agendas (Kitson et al, 1998)

The ROYAL

HOSPITALS

4. Creating a learning environment4. Creating a learning environment

Improve the knowledge base among staff at all levels in terms of:Improve the knowledge base among staff at all levels in terms of:• Identifying appropriate questions for ‘new’ research and Identifying appropriate questions for ‘new’ research and

distinguishing between the need for new research versus the distinguishing between the need for new research versus the implementation of existing knowledge.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 The use of systematic approaches to audit and evaluation in

order to transfer knowledge into practice.order to transfer knowledge into practice.• Reading research critically and understanding how to make Reading research critically and understanding how to make

judicious use of research in practice.judicious use of research in practice.

The ROYAL

HOSPITALS

Develop staff knowledge in approaches to developing a Develop staff knowledge in approaches to developing a culture of ‘critical inquiry’ in practice settings:culture of ‘critical inquiry’ in practice settings:

• Increase awareness of approaches to reflective Increase awareness of approaches to reflective practice.practice.

• Develop an understanding of the way knowledge can Develop an understanding of the way knowledge can be generated from practice as a legitimate research be generated from practice as a legitimate research activity in itself.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 Help clinical leaders identify the readiness of their

practice context for critical inquiry.practice context for critical inquiry.

The ROYAL

HOSPITALS

"The reasonable man adapts "The reasonable man adapts himself to the world; the himself to the world; the unreasonable man persists in unreasonable man persists in trying to adapt the world to trying to adapt the world to himself. Therefore, all progress himself. Therefore, all progress depends on the unreasonable depends on the unreasonable man”man”

[George Bernard Shaw, 1856-1950][George Bernard Shaw, 1856-1950]