The aim of this article is to answer some of these questions and to demystify the whole concept of practice development.

Practice development is a term used to describe activities designed to help healthcare professionals approach their work in ways that will provide care that patients feel is right for them. In other words, it is about anything that ultimately improves patient care. One example is reflective practice, which involves looking at what we are doing and why we are doing it. Practice development is something that we all aspire to do on a day-to-day basis, and it is part of everyone's role.

The practice development vision

Barts and The London NHS Trust's vision for practice development is: 'Developing a Trust-wide culture of effectiveness, one that is patient-centred and evidence-based'.

This means all healthcare professionals working together to look at the way things are done in their clinical area or workplace. It also includes a work culture where people feel they are listened to and where they can develop their ideas.

Eleven objectives have been developed to move practice development forward within the Trust:

1. To improve the patient's experience.
2. To improve the patient's outcome.
3. To provide more opportunities for patient/user involvement.
4. To increase evidence-based care.
5. To promote access to all forms of evidence and enable practitioners to develop, critique and use all forms of evidence.
6. To develop corporate and local mechanisms for providing feedback on unit and departmental effectiveness.
7. To develop a workplace culture that is person- and patient-centred.
8. To develop everyone's leadership potential across the Trust.
9. To develop a learning culture.
10. To implement systems of clinical supervision/action learning in all areas.
11. To introduce 360-degree feedback across the Trust.

Collectively, these objectives form the basis for the practice development strategy.

The eleven objectives aim to create a culture of transformational leadership. This means enabling everyone to develop their leadership skills and potential by:

• Developing a shared vision
• Inspiring and communicating
• Valuing others
• Challenging and stimulating
• Developing trust
• Enabling others

From these eleven objectives, local action plans have been devised to relate the objectives to local clinical areas. So what do they all mean? If we look at each of the objectives individually, they should become clearer and more easily related to day-to-day practice.

Sharing best practice is a way to improve patient experience. This can be demonstrated by the work undertaken by the Clinical Practice Nursing Team on the new Nil-by-Mouth policy (NBM). This policy was developed by a multi-professional group which shared evidence and best practices to try to end inappropriate fasting of patients preoperatively. The end result of this was the new NBM policy, which was implemented in all areas of the Trust in April 2003. Now, instead of starving a patient from 12 midnight as was routinely done before, the patient must stop eating six hours prior to surgery and then may continue to have water only up to two hours before surgery. Then the patient must remain NBM.

To improve the patient outcomes

This can be achieved through the work that is going on in relation to the Essence of Care benchmarks, and the practice changes that have occurred because of this. Examples include: decorating patients' dayrooms and providing better facilities, so that patients do not have to eat by their beds; purchasing ablution jugs for our Muslim patients; and placing 'do not disturb' signs on curtains pulled closed around patients' beds - to name but a few of the many practice changes that have occurred.

All of these help to improve the outcome of the care received by our patients.

There are many ways in which the Trust can provide opportunities for patient involvement, including the new Trust Patients' Forum. But how can we at a local level achieve this?

One example is a clinical area that has a 'drop in' afternoon on Wednesdays, giving patients and relatives the chance to talk to the ward sister, senior nurse and others involved in their care, if they have not had the opportunity to do this at other times during the week.

Another example is the recent Picker Report and the action plans that have been developed based on the results of this. The Picker Report is compiled by an outside company, which sent questionnaires to patients who had received care in our hospitals to find out what they thought about the service they had received. Areas for action were identified in the report.

Some areas have journal clubs or clinical practice forums where they review the latest evidence available for health care in their area. Other departments work in collaboration with City University or with Angela Grange, Research Facilitator for Nurses, Midwives and AHPs, to undertake their own research projects.

Another example is the Clinical Effectiveness Unit

There are also the four shared governance nursing teams (Clinical Practice, Quality, Management & Education) within the Trust, which all participate in various projects around the Trust, enabling practitioners to develop, critique and use forms of evidence in day-to-day practices. Examples of work that the teams have been involved in include the NBM policy (mentioned above), integrated notes, preceptorship programmes, and the nursing generic orientation programme.

This can include everything from multidisciplinary meetings and case conferences, team and departmental meetings, through to ensuring that everyone in the team receives feedback from compliments, incidents and complaints. Corporately this may be done through the clinical governance forums and other Trust committees.

To develop a work place culture that person- and patient- centred

Guidelines are currently been developed to help all staff in the Trust, objectively observe the care given in their clinical area. This is called an 'Observation of Care study'.

One recent Observation of Care which was carried out on two wards in the Trust identified issues around communication amongst the MDT team and patients. One of the action plans of this Observation of Care was to hold workshops for all ward staff on communication using role-play as a teaching method.

Like the patient stories, if you are interested in developing your skills in objectively observing patient care and constructively feeding this information back to the team, please join one of the Practice Development workshops.

Many leadership courses are available within and outside of the Trust. Clinical leaders empower the workforce in their clinical area, ultimately leading to improved patient care. Barts and The London, in conjunction with the Royal College of Nursing, is running a clinical leadership programme, which aims to help clinical leaders to develop leadership potential and manage teams more effectively. The first cohort of these clinical leaders commenced the programme in April 2003.

To develop a learning culture

Culture is defined as 'the way things are done around here' (Drennan 1992).

The Trust has numerous opportunities for learning. These include in-house study days, teaching sessions, awaydays, workshops, links with City University, teaching post for teaching sisters, practice development nurses and facilitators, nurse specialists and other specialists allied to medicine, among others.

Clinical supervision is a formal arrangement that enables practitioners to discuss their work regularly with another experienced professional. It involves reflecting on practice in order to learn from experience and improve competence. Clinical supervision is available for staff across the Trust.

Action learning is a continuous process of learning and reflection supported by colleagues with an intention of getting things done. Practice development practitioners within directorates will be able to provide more information on action learning.

Informal methods of reflection include mentoring, preceptorship, clinical incident debriefing and buddying, and these are happening across the Trust every day.

This is an opportunity for individuals to gain feedback on their performance from everyone that they work with. 360-degree feedback involves data collected from a range of people who have an interest in an individual's work - including peers, managers, senior staff junior staff as well as other disciplines they may work with. The purpose of the data collection is so that the practitioner can reflect on the feedback in relation to the assessment of their own expertise. Examples of some questions that might be asked as part of a 360-degree feedback include:

• What feedback could you give me to be more effective in my role?
• What have you experienced that I need to develop/refine/work on?
• What areas have you experienced that I do well?

I hope these examples have clarified and helped make sense of the 11 objectives that make up the practice development strategy.

Practice development is everyone's business. We should be working together in our clinical areas using the skills highlighted. This will ultimately create a culture of transformational leadership that will enable patient-centred care.

Acknowledgement

The Practice Development Team

Reference

1. Garbett & McCormack. A Concept Analysis of Practice Development. NT Research 2002; 7.2: 87-99.