Nursing development units: their structure and orientation

The Norwegian teaching home program: developing a model for systematic practice development in the nursing home sector

Background.  In the mid-1990s, there was persistent critique of the quality of care provided in residential aged care facilities in Norway, in line with similar concerns expressed in many other countries. Difficulties recruiting qualified staff and high turnover led to difficult working conditions. Little prestige was associated with providing geriatric care. Collaboration between educational institutions, universities and elderly care institutions with the purpose of strengthening education, competence development, practice development and research within elderly care was poorly developed. The Norwegian teaching nursing home (NTNH) program was launched to address these issues. Aim.  The purpose of the NTNH was to contribute to the quality of care of frail older persons by improving the competence of staff, improving the prestige of working with older people, stimulating development of services, facilitating research into the care of older persons, and developing good learning environments for students. Methods.  The NTNH-program was developed over a period of seven years, applying a participatory action research design. Progressing through four phases, it involved a number of people and institutions across Norway. Results.  Formal and informal competence of staff was increased. A large number of practice development projects contributed to increased quality of care in selected problem areas. Models of competence development were disseminated to other institutions, thereby improving the level of competence beyond the NTNHs. Learning conditions for students were improved. Following a formal evaluation of the program, teaching nursing homes (TNHs) were established on a permanent basis in 2004, with financial support from the Department of Health and Social Services. In 2008, a total of 20 TNHs are part of the NTNH program. Conclusions.  The NTNH program led to permanent establishment of a series of TNHs responsible for contributing to competence development, practice development and research on a continuous basis in order to secure high levels of care to the Norwegian nursing home population. The program has created substantial enthusiasm within the nursing home sector and has increased the prestige of these institutions.

The impact of nursing innovations in the context of governance and incentives

This discursive paper is a structured analysis of four completed national and regional studies carried out in the UK. It sets out retrospectively to explore the impact of key contextual, professional and personal features and mechanisms on innovation and outcomes in nursing and the extent to which these are common or diverge across the studies (cases).

As successive governments across the world turn their attention to developing nursing as a means of increasing productivity and effectiveness in health care, there is a need for evidence to inform workforce policy and planning about the circumstances that enable positive levers and mechanisms, which influence outcomes to operate. This analysis takes advantage of recent conceptual work on organisational governance and incentives by asking new questions of established data to illuminate our understanding of the pathway to innovation in nursing.

Data from the four evaluations (cases) were aggregated and explored thematically within Davies et al.’s framework (Studying health care organisations — links between governance, incentives and outcomes: a review of the literature. Report for the National Co-ordinating Centre for NHS Service Delivery and Organisation R&D (NCCSDO). http://www.sdo.nihr.ac.uk/files/project/66-final-report.pdf, 2005) of governance, incentives and outcomes. The themes were grouped into three categories: contextual, professional and personal, and interrogated by inter-researcher scrutiny.

Taking account of the limitations of comparing studies carried out for different purposes and in different policy circumstances, there are compelling messages emerging about the organisational support, professional leadership and factors that motivate change and innovation in nursing. The analysis suggests that separating governance from incentives oversimplifies what is a complex interplay between organisational governance and the professional and personal enabling factors supporting innovation. The nature of these relationships deserves further study.

Reflections on a 'virtual' practice development unit: changing practice through identity development

AIMS

This paper draws together the personal thoughts and critical reflections of key people involved in the establishment of a 'virtual' practice development unit of clinical nurse specialists in the south of England.

BACKGROUND

This practice development unit is 'virtual' in that it is not constrained by physical or specialty boundaries. It became the first group of Trust-wide clinical nurse specialists to be accredited in the UK as a practice development unit in 2004.

DESIGN AND METHODS

The local university was asked to facilitate the accreditation process via 11 two-hour audio-recorded learning sessions. Critical reflections from practice development unit members, leaders and university staff were written 12 months after successful accreditation, and the framework of their content analysed.

FINDINGS AND DISCUSSION

Practice development was seen as a way for the clinical nurse specialists to realize their potential for improving patient care by transforming care practice in a collaborative, interprofessional and evolutionary manner. The practice development unit provided a means for these nurses to analyse their role and function within the Trust. Roberts' identity development model for nursing serves as a useful theoretical underpinning for the reflections contained in this paper.

CONCLUSIONS

These narratives provide another example of nurses making the effort to shape and contribute to patient care through organizational redesign. This group of nurses began to realize that the structure of the practice development unit process provided them with the means to analyse their role and function within the organization and, as they reflected on this structure, their behaviour began to change.

RELEVANCE TO CLINICAL PRACTICE

Evidence from these reflections supports the view that practice development unit participants have secured a positive and professional identity and are, therefore, better able to improve the patient experience.

Practice development 'without walls' and the quandary of corporate practice

AIM

The context of this study is a group of clinical nurse specialists from across a Trust seeking accreditation as a practice development unit. The university was asked to facilitate the accreditation process via 11 2-hour learning sessions (including a one-hour focus group). During initial discussions between the university and practice development unit, the overarching research question for this study was set as: 'what are the main roles and responsibilities of clinical nurse specialists?'

BACKGROUND

Although there is no known study of a practice development unit based beyond a ward or speciality, the central tenet of the practice development unit literature is that units must demonstrate their worth if they are to survive and harness senior management support in doing so.

DESIGN AND METHODS

Data gleaned from the transcribed audio tape-recordings of the learning sessions were studied at least three times to ensure transcription accuracy and produce detailed charts. Ethical approval was granted by the appropriate Local Research Ethics Committee and written informed consent obtained from clinical nurse specialists. The study lasted 30 months and ended in October 2004.

RESULTS

The four crucial statements that give meaning to specialist practice are: quality care giver; expert; information giver and initiator of change. Further analysis reveals the area of corporate and political practice as being missing from this and other lists of clinical nurse specialist attributes found in the literature. Clinical nurse specialists characterize their relationship with the Trust in terms of dichotomy--differing agendas and perceptions of value.

CONCLUSIONS

The specialist role requires professional development in the areas of corporate and political acumen and professional business management. While the findings of this study relate to one Trust and a group of 16 clinical nurse specialists, with careful application they may be transferable to other settings and groups of senior nurses.

A clinical development unit in cardiology: The way forward

The clinical development unit (CDU) has been recognized as an effective strategy to progress creativity and resourcefulness in nursing practice to improve patient outcomes. Clinical development units, through transformational leadership, promote staff development, the use of research evidence and dissemination of research findings through publication and presentations. The aim of this paper is to clearly articulate the processes (in particular, research and education initiatives) related to the development of staff that address issues in the everyday workplace and, accordingly, have been instrumental in the success of the creation of a CDU in cardiology. These units aim to achieve and promote excellence in an identifiable area of nursing using a systematic, transparent and defensible approach. A review of acute coronary syndrome informed the needs and direction of staff activities in the cardiology unit of a tertiary referral hospital. Through a collaborative staff approach, evidence was carefully examined to plan its appropriate adoption into the clinical area. Nursing practice and education resulting from this review was scheduled into staff career progression. These initiatives have been incorporated into staff development learning, enabling the integration of research into practice, which ultimately has a positive impact on patient outcomes.

'Working from the inside': an infrastructure for the continuing development of nurses' professional clinical practice

AIM

This paper describes how the nursing executive of a tertiary referral facility revisited their management structures and responsibilities to create a new, sustainable infrastructure that supports research and education at the core of nursing practice and not at the periphery.

BACKGROUND

Nursing executive and senior management groups are charged with the ultimate responsibility of ensuring the highest possible quality nursing care within their facility. In the current health care climate the aim for best practice conflates with evidence-based practice that can be notoriously difficult to achieve due to the many barriers to integrating research findings into practice.

KEY ISSUES

Research and education activities have been established as fundamental to core business under a simple evidence-based practice model.

CONCLUSION

The value of a synthesis between the clinical areas with the nursing education and research division has been recognized to better achieve the goal of improved services.

Processes, outcomes and evaluation: challenges to practice development in gerontological nursing

When aligned to participants' needs, evaluation may be used to enhance practice developers' work. Process evaluation enables practice developers to evaluate as they develop; making evaluation an integral part of practice development rather than an 'add on task'. It is contended that beginning practice developers can discharge their need to evaluate their work through the practice development techniques of critical reflection, dialogue and action learning. These form the basis of iterative and formative evaluation activity. However other types of evaluation are important for different audiences in practice development. Consideration of the purpose and utility of evaluation in a range of contexts in which gerontological nursing occurs, brings some clarity regarding the scope of the evaluation required to sustain practice development initiatives. In addition, it helps to clarify the nature of the evaluation required to provide evidence of patient-centred outcomes from developments in the practice of gerontological nursing.

The Centre for Psychiatric Nursing Research and Practice: an innovative approach to enhancing clinical nursing research in the psychiatric/mental health field

The available nursing literature suggests that nurses engaged in clinical practice hold a somewhat ambivalent attitude towards nursing research. On the one hand, its value is acknowledged, but on the other, its relevance to clinical practice is questioned. This situation poses a significant barrier to the involvement of clinicians in research and the utilisation of findings in practice. This paper describes the implementation of a model to facilitate the development of a systematic research approach at the Centre for Psychiatric Nursing Research and Practice in Victoria, Australia. The development of strong relationships between the Centre and the clinical field was considered crucial in determining the success of this initiative. The introduction of a number of programs to foster the conduct and utilisation of clinical research are described, including: The Nursing Clinical Development Unit Program, the Clinical Research Fellowship Program, clinical research projects, the Collaborative Psychiatric Nursing Conference and strategies to encourage the dissemination of research information. In combination, these initiatives are expected to contribute to a systematic approach to engendering a research culture within psychiatric nursing in Victoria, Australia.

The lived experience of clinical development unit (nursing) leadership in Western Sydney, Australia

BACKGROUND

A network of nine Clinical Development Units (Nursing) (CDU(N)) were recently created in the Western Sydney Area Health Service. These units are designed to develop patient-focused nursing practice through group process and action research, based on principles of transformational leadership.

AIMS OF THE STUDY

Although there is documented evidence from Australia and the United Kingdom (UK) that CDUs and Nursing Development Units (NDUs) are very successful in improving both patient and staff satisfaction, there is also growing evidence that the stressors experienced by nurse leaders are threatening the survival of some of these units. This study set out to develop an understanding of the phenomena of Clinical Development Unit (Nursing) leadership when these stressors were likely to impinge.

STUDY DESIGN

Hermeneutic phenomenology was employed in order to identify how these experiences changed over time. Two rounds of interviews were conducted: approximately 4--6 months after the launch and, again, 12 months later.

FINDINGS

The Clinical Development Unit (Nursing) philosophy provided a framework on which these very motivated leaders began to enhance nursing accountability in their units through reflective practice and participatory governance. While reinforcing many previously published positive and negative aspects of Clinical Development Units and Nursing Development Units, this paper also highlights how the expectations and experiences of these leaders changed over time with unanticipated pressures of work, a high turnover of clinical leaders, a perceived diminution of management support and unrealistic self-expectations. A significant theme that emerged as these stressors began to impinge was the leaders' own need for leadership in order to sustain their confidence and motivation.

IMPLICATIONS FOR NURSING

Insights harvested from this study have since been incorporated into a revised leadership preparation programme and support mechanisms for the leaders of eight new Clinical Development Units (Nursing) in the Western Sydney Area Health Service.

A pluralistic evaluation of nursing/practice development units

Nursing/practice development units (N/PDU) are perceived as centres for pioneering, evaluating and disseminating innovative practice development and facilitating the professional development of practitioners. This paper reports on a pluralistic evaluation research study of the nursing/ practice development unit accreditation programme provided by the University of Leeds, UK. Individual and focus group interviews were undertaken with key stakeholders involved in six nursing/practice development units. These included: clinical leaders, team members, executive nurses, trust board members, general medical practitioners, nursing/practice development unit steering group members, and accreditation panel members. Stakeholder perceptions of what constituted a successful nursing/practice development unit were elicited and then used to judge the success of the programme. Seven criteria for judging the success of nursing/practice development units were identified. These were: achieving optimum practice; providing a patient-orientated service; disseminating innovative practice; team working; enabling practitioners to develop their full potential; adopting a strategic approach to change and autonomous functioning. The findings highlighted differences between the rhetoric of a successful nursing/practice development unit and the reality in which they function. Whereas all the units were actively involved in innovative practice development, evaluation, dissemination and networking activities, several factors influenced the success of the units, in particular, the role of the clinical leader, the motivation and commitment of nursing/practice development unit members, financial resources, and the nature of support from managers, medical staff and education institutions. Although the nursing/practice development units had made significant progress in developing both healthcare practice and practitioners, there is still a need to consider how the claim that nursing/practice development units benefit patients can be substantiated.

Nursing development units: factors influencing their progress

Nursing development units (NDUs) have long been advocated as 'test-beds' for pioneering leading-edge practice development. This article reports on the findings of a study examining factors influencing the development of NDUs, and, more recently, established multidisciplinary practice development units (PDUs). Individual and focus group interviews were undertaken with key stakeholders involved in six NDUs/PDUs accredited by the University of Leeds. The findings from the study highlight a number of internal and external factors that have impacted upon the progress made by these units. Importantly, the role of the clinical leader, the staffing establishment, organizational infrastructures to facilitate dissemination and the nature of the support from managers and medical staff have all influenced the success of the NDUs/PDUs. In order to ensure the long-term viability of an NDU/PDU it is essential that practice development is planned and managed in a systematic and coordinated way with a full appraisal undertaken of the human, physical and financial resources necessary to implement and disseminate change and that the work of the NDU/PDU is incorporated in the trust's strategic plans in order to ensure organizational support.