Summary of the impact

Bournemouth University (BU) has facilitated improvements to health and social care practice through cultural change in care provision. Researchers developed a practice development framework for implementing and assessing the delivery of evidence-based practice in 82 UK health and social care units during the impact period. Benefits to staff include better communication and team structure. Benefits to patients include higher standards of cleanliness, privacy and dignity, as well as a decrease in length of hospital stays and appointment waiting times. Delivery has extended to cover entire NHS Trusts serving a resident population of over 3.5 million, social services departments and third sector organisations across the south of England and beyond. The research has since been applied to develop a similar system in Australia.

Underpinning research

The term `practice development' evolved from the work of a small number of nursing development units (NDU's) in England during the 1990's. Those in the South of England were facilitated by BU. The aim, based on research by Graham (BU 1994-2007), was to reduce the theory-practice gap, increase use of evidence-based practice, develop a better educated workforce and move away from the traditional medical model towards more patient-focused care.

After recognition at the time that this agenda could only be achieved through multi-disciplinary working, there was a shift from nursing-specific development to the wider concept of inter-professional practice development. BU researchers Warr (BU 2011 to present), McSherry (BU 2008-2008), Graham and Keen (BU 2004 to present), focused on practice development approaches that would work across a wide variety of health and social care settings (P1&2), including NHS Trusts, social services departments and other organisations.

The research group identified a need for teams to question and challenge current practice and, by using evidence, improve services. The following research themes emerged, which form the basis of the standards of the Practice Development Units (PDUs) BU went on to establish:

- Practice development is intended to improve person-focused care.

- Practice development should be practitioner owned and should empower practitioners to instigate change.

- To be effective practice development needs to bring about cultural change.

- Practice development improves practice through the systematic introduction of evidence- based care.

From this, they established an explicit set of standards to measure the quality of units against, allowing successful departments to gain PDU accreditation or status. Specific information on these measures and the accreditation process is detailed in the impact section of this case study. More recently, researchers Todres (BU 1996 to present), Galvin (BU 1995-2012), Holloway (BU 2011 to present) and Hewitt-Taylor (BU 2002 to present) have examined the practice development approach in a wide variety of settings, such as specialist dementia (P6) and children's (P4) services. The department's current research into `humanisation' theory is now being integrated into the process to further enhance the quality of fundamental care offered to service users (Francis Report 2009, 2013). Humanisation of care is based on the principle that restoring humanly sensitive care is about how the `humanising focus' is clearly articulated and kept alive as a primary focus, next to other relevant targets. This theory has emerged from pioneering research and philosophical work undertaken by BU (P3).

Practice development is a continuous process of culture change and service improvement through enabling teams to transform the culture and context of care (Francis Report 2009, 2013). It is supported by facilitators committed to a systematic, rigorous and continuous process of emancipatory change.

References to the research

Publications

Grants

G1. 2008: Directly commissioned to undertake Practice Development Accreditation for new Children Centre Teams x 4 (a case study for the Department of Health) - £31,000. PI: Andrews, C.

G2. Each practice development unit has been funded by their NHS or Local Authority organisation - £7,500. This amounts to over half a million pounds in total. PI: Andrews, C.

G3. 2009: Five Rivers KTP Research Council Funded - £180,000, Technology Strategy Board. PI: Andrews, C.

G4. 2010: Help & Care KTP Research Council Funded - £192,556, Technology Strategy Board. PI: Hean, S.

Details of the impact

BU's practice development approach is now widely used in England (R1) with further evidence of use in Australia (R2). This helps health and social care practitioners to use the best available evidence to develop their practice and ensure their care is effective and person focused.Through the practice development process and accreditation teams work towards developing a culture of excellence by becoming person-centred and introducing evidence-based practice through effective culture change and teamwork. Teams are encouraged to question and challenge current practice and, by using evidence, improve services. Each PDU must demonstrate:

- An understanding of the service user needs and clear mechanisms for communicating and listening to users and carers.

- How developments are researched, evidence-based, evaluated and disseminated to demonstrate best practice and to contribute to the local, national and international evidence base.

- A clear action plan that outlines the aims for development of services and team members that has links to national and local host organisation's priorities.

- A leadership structure that supports the delivery and development of multi-agency inter- professional care in line with the action plan.

- A defined communication structure to ensure the collaboration of team members and the provision of effective inter-professional care.

- A clear understanding of the user journey and understanding of the team member's contribution to the success of the user experience.

- How services have been developed taking a `whole systems' approach, ensuring the entire user journey is improved.

- Clear partnerships with an academic department and other agencies required to support research and the dissemination of best practice.

This explicit set of standards is then assessed by a panel of external experts from practice and academia who examine a portfolio of evidence and visit the unit to observe and speak to service users, carers and staff. Units are reaccredited on a three-yearly basis to ensure high standards are maintained.

Since 2008, BU researchers have facilitated the set-up and accreditation of 47 PDUs and reaccreditation of 35 (Fig. 1), working with 82 units in total. This covers 6 counties in the UK (Fig. 2), including 8 NHS Trusts serving a resident population of over 3.5 million (R3). Units accredited and reaccredited include social services departments, dementia services and children's units (R4).

The overarching impact of BU's practice development process is a change in culture, leadership and team creation. There is an extensive list of NHS and social care unit contacts that can corroborate this, demonstrating an effective move to evidence-based practice, improved communication between staff and service users and consistently improved inter-agency working. These include the following testimonials:

"Developments through practice development include pioneering work in helping young people with chronic conditions make the difficult transition from children's to adult services; making improvements to cleanliness; working with the public and patients to revise visiting times and protect patient privacy and dignity; introducing matron ward rounds and reducing waiting times for echo-cardiograms." Cardiology Department Matron — Poole Hospital NHS Foundation Trust (R5).

"Implementation of a new pain pathway through practice development after total knee replacement led to reduced pain and 0.5 day reduction in length of stay." Orthopaedic Unit Ward Manager, Poole Hospital NHS Foundation Trust (R6).

Organisations reap the benefits of multi-disciplinary teams and a multi-agency approach, as well as new leadership roles. Some further specific and measurable impacts include:

- The North Essex NHS Foundation Trust `Patient Pathway', introduced through BU's practice development process in February 2010. This was achieved by establishing working groups who introduced training, amended recruitment criteria and implemented essence of care benchmarking for communication skills and continence management. One year later, there was an overall change in occupancy days since the pathway was introduced. In one ward the bed days reduced by 599 days overall, a 50 % reduction in length of stay of patients. This in turn reduces waiting lists and increases cost effective for the NHS.

- The PDU at Poole Hospital NHS Foundation Trust led to streamlined allergy testing in 2011, through the simplification of referral and appointment cancellation mechanisms. This resulted in appointment waiting times reduced from 13 weeks to 2 weeks.

Other reported benefits of practice development include a reduction in pain through pain management pathways, improvements to cleanliness, more patient-friendly visiting times and protection of patient privacy and dignity. Benefits on practice include better communication between staff and carers, a reduction in `inappropriate admissions', more effective team organisation and increased funding from service commissioners.

These benefits make a significant difference to treatment of patients and working lives of staff in Trusts serving a collective resident population of over 3.5 million. The changes are also contributing to a wider cultural change, which is necessary to improve care. The continuing impact of this research is evident through the development of PDU master classes in Australia, formed from the basis of BU programmes (R2).

Sources to corroborate the impact

R1. Crisp, J. and Wilson, V. (2011). How do facilitators of PD gain expertise to support transformation of practice and workplace culture? Nurse Education in Practice, 11(3), 173-178. DOI: 10.1016/j.nepr.2010.08.005.

R2. Hardy, S., Bolster, D., Kelly, T. and Yalden, J. (2012). Enhancing facilitation skills through a practice development masterclass. Australian Journal of Advanced Nursing, 29(2), 36-47. Available from: http://www.ajan.com.au/Vol29/29-2_Hardy.pdf [accessed 21 November 2013].

R3. Sources for each NHS Trust sizes available on request.

R4. Statistics for Figures 1 and 2 available on request.

R5. Cardiology Department Matron, Poole Hospital NHS Foundation Trust.

R6. Orthopaedic Unit Ward Manager, Poole Hospital NHS Foundation Trust.

R7. Gallagher, J. and Fuggle, K. (2012). The Ideal way to rejuvenate our service. Journal of Dementia Care, 20(3), 14-15.

R8. Fitzgerald, A. (2008). Dementia Project One of UK`s Best. Maldon & Burnham Essex Chronicle.

R9. North Essex NHS Foundation Trust (2010). PDU Plaque Ceremony Triumph, Crystal Centre Newsletter, Essex County Council.

R10. Deep South Media (2012). Dorset Care Homes Celebrate Badge of Excellence. Colten Care Press Release.

R11. Dr Ann Hemingway: part of award winning public health PDU team winning the DOH Health and Social Care Award 2009 for partnership working on improving the sexual health of young people.

R12. Elson, J. (2010). Accreditation is the culmination of staff`s efforts to improve services and ultimately the standards of care that we provide. Director for Older Peoples Services Dorset Healthcare NHS Foundation Trust. The Beacon, Spring, 11.

R13. Fuggle, K. and Gallagher, J. (2012). Redesigning dementia care through Practice Development Accreditation (HR Manager and Operations Manager Colten Care Nursing Homes). The Beacon, Summer, 12-13.