MEASURES, PROCESS OR OUTCOME: DEVELOPING A NEW VOCABULARY TO GENERATE PRACTICE-BASED NARRATIVES
Applying qualitative outcomes to practice
"Plato's problem: How can we know so much when the evidence is so slight?"
Chomsky, N
Cited in "Chomsky, Ideas and Ideals"
Dianne Hinds
Bournemouth University
In collaboration with:
Dr Les Todres
Paper presented at the Qualitative Evidence-based Practice Conference, Coventry University, May 15-17 2000.
Applying Qualitative Outcomes to Practice
Introduction
Perhaps this contribution would more appropriately be entitled: Measures, Process or outcomes: fostering a capacity for vocabulary development enabling the generation of practice based narratives. The abstract refers to "authentic voice” but in this paper I shall attempt to highlight the complexity of fostering what Wilmot (1995) names “authentic professional dialogue” in an endeavour to tease out issues inhibiting the articulation of such a voice.
The notion of applying qualitative outcomes to practice subsumes a number of questions germane to the project on which this paper is based. The life of the Regional Interprofessional Education Project is midway, but issues raised reflect the NHS modernisation agendas regarding the development of practice knowledge in the workplace, aspects of professional knowledge development, and theorising about such knowledge as elements of social care and health service improvement.
A number of issues addressing the application of qualitative outcomes to practice reflect tensions within the new NHS modernisation agenda. These relate to development and change within the working environment. In this paper I shall attempt to explore some of the contradictions and tensions implicit in driving forwards this agenda as evidenced within the project with which I am involved, which is firmly located in the 'swampy lowlands' of professional development. The unarticulated assumption is that fundamentally the task of developing a new vocabulary, and generating practice based narratives for service improvement outcomes represent learning endeavours. Developing an environment to enable and sustain such learning represents a major challenge, particularly when agendas are framed within a transformed socio-political context.
Key questions underpinning the application of qualitative outcomes originate in the genesis of the outcome. The notion of an outcome is in itself a construct frequently associated within an instrumental framework. The tension within educational research of process versus outcome frequently obtains within evaluation paradigms, but indicate how language constructs 'reality' and shapes experience. These key questions regarding outcomes appear to me to be:
Who has generated the outcomes?
Who owns the outcomes?
Outcomes as evidence?
All these questions are embedded implicitly in this paper in which I shall endeavour to:
- Describe the project from which this paper is drawn
- Consider learning and change and professional development as necessary ingredients for service improvement
- The socio-political context - drivers for change
- Learning and change
- Appreciating an underlying language awareness
- Shifting learning perspectives
- Highlight dialogue and conversation as key aspects within the learning process
.
These bullet points may appear antithetical to a paper focusing onto narrative approaches, but may be considered as steps of the journey to producing narrative accounts from which to develop qualitative outcomes.
Intertwined within these points selective vignettes drawn from data gathered within the project will highlight the process of change as experienced by members of the collaborative, and illuminate this complex process.
This project
The Regional Interprofessional Education Project (RIPE), represents one aspect of an National Health Service Executive South West (NHSESW) collaboration. With a combined focus on interprofessional learning, service improvement, and collaboration, the learning emphasis transcends traditional divides implied within training and education. In this model selective barriers have been removed to promote collaborative relationships at a number of levels.
The collaborative thrust of the initiative is reflected in the relationship between the university team including practice teachers, CQI facilitators and health and social care service providers. These collaborations are known by the NHSE as Local Improvement Teams (LITs).
At the operational level interprofessional action learning sets adopt a needs-centred continuous quality improvement (CQI) model in order to improve and develop services. This is known as the Plan Do Study Act cycle.
The project operates within three different locations, the first within a trust community based mental health team, the second within a hospital where the focus is on elderly care with a third setting focusing on services delivered within the auspices of a child and family services NHS community trust.
The membership of each group is unique. In the hospital setting two teams meet with the university team every six weeks. Both teams include consultants and a range of nursing and therapeutic staff. In the child and family support services health visitors, management of the trust, voluntary agency personnel and service user organisation representatives are currently actively engaged. Within the community based mental health team a general practitioner, community psychiatric nurses, occupational therapists and a service user development worker form the core of a group whose boundaries have frequently changed.
One key feature of the Project evaluation is to capture, evaluate and disseminate the learning within the interprofessional learning sets. The evaluation focuses on telling the story of the improvement, and that of the learners.
Embedded within this evaluation are key questions relating to the ability of the LIT to carry out small action research activities based on the generation of identified solutions to particular service user scenarios. Key in the evaluation vocabulary are questions concerning the ability of local improvement teams to accelerate efforts towards local health improvement, and to identify and measure key variables. There is, within the continuous quality improvement model a close link between measurement and improvement in health care. These elements are considered to be closely intertwined. However, there is a recognition that measures are "meant to reflect reality but they are not reality itself." (Nelson, Splaine, Batalden and Plume, 1998)
Evaluation outcomes maintain Lincoln and Guba (1989) refer not to descriptions of “the way things really are”, but instead make meaningful constructions of the way individual actors of groups of actors form "to make sense of the situations in which they find themselves”.
There is a strong process orientation to the narrative of an emergent case study, with both education and health improvement outcomes identified as elements of educational process.
There is then a tension, such as that alluded to by Eraut (1998) between short term performance management goals, and the longer term human resource management framework. The term ‘capability’ has emerged as a key term within the project, representing a longer term capacity as an educational process outcome. Such capabilities may be fostered as a consequence of the learning environment and organisational culture. These aspects are crucial within the implementation of the NHS improvement agenda.
The socio political context – drivers for change and improvement
In the modernisation program outlined within The New, Modern NHS, a radical shift in power relationships between the patient/service user/consumer and the health and social care professionals engaged in service delivery is outlined. The rhetoric of ‘seamlessness’ is presented as one strand of improvement. This language of improvement in health care is central to ‘quality‘ issues, articulated within the development of ‘client’ centred approaches.
Underlying these changes are implied shifts within what may be regarded as the ‘traditional’ medical value base to one driven by an agenda of social justice. As such it reflects a value base clearly articulated within the sphere of social work. Thus, in the move away from a medical model to a social care model, implicit tensions based on these issues may emerge.
Batstone & Edwards (1996) anticipated the government reforms in highlighting structural dilemmas posed to Trusts responsible for integrating postgraduate medical education programmes. Multiprofessional education was seen to be the key to promoting clinical effectiveness (in the guise of common strands of continuing professional development). Separate professional groups exacerbated fragmentation in developing evidence based practices. Finally Batstone & Edwards concluded that models employing top down change processes rather than utilising educational techniques were not likely to foster successful multiprofessional education.
The emphasis on ‘quality’ within the current reformist agenda incorporates a range of systemic initiatives designed to generate and promote learning across professional groups. The reforming agenda includes clinical effectiveness, clinical governance, and a massive endorsement of the need to shift towards a health care team.
The rhetoric embodied in notions such as lifelong learning and individual learning plans is placed in a continuous dialectic with the language of targets and measures. The recent introduction of the NHS Learning Network to support learning and sharing of good practice, requires particular attention in one vital respect, suggests Garside (1999), in the context of the learning organisation as applied to the NHS. The implementation of findings derived from external initiatives within the prevailing ‘culture of blame’ and local systemic turbulence requires close close attention to the receiving and local environment in which the change is to occur. Changes in practice involve unlearning established practices.
As Garside (1999) points out, to support a system capable of learning at all levels requires a cultural shift to become more proactive. Such a shift requires a culture of learning, supported by communication and educational processes. Learning requires embedding within the organisational culture.
Before addressing the area of learning and change, I shall introduce several critical features regarding the nature of the learning environment, or organisational culture. Essentially these focus on the nature of the learning environment, and the need to generate individual meanings of innovation within implementation.
A cameo within the following section illustrates a change of practice within this innovation.
Fostering learning and change
Key assumptions underpinning this section focus on learning and service improvement as core components of a continuous quality improvement orientation. For the organisation this means fostering an environment to support continuous learning.
Eraut considers the internal culture of organisation to be an important ingredient in developing a quality scenario. In addition to serving client interests, sustaining an appropriate climate, supporting and developing staff, are also relevant. Expanding on the 'hidden curriculum' of a work environment where professed theories contradict theories in use Eraut points out failing to allocate time to deliberate on practice may lead to a situation where: "Learning comes to be regarded as a subversive activity, and all change is perceived as a threat." (p238). Both time and attention were found to be important elements to promote learning in the workplace (Eraut, 1998). This aspect has been reflected within the emergent project outcomes. Despite tension with service demands, for those individuals with full time working commitments this appears to be an important element within the learning process.
Inexorably entwined with the issues relating to learning and change is the paradox that "change is a learning process and learning is a change process" (Garside, 1999). Fullan (1982), writing on the meaning of educational change focuses on distinctions between change and change processes. He observes that there is a failure to apprehend the change process as a learning process. This is a crucial element frequently ignored within implementation.
Tensions exist, primarily between the top down government agenda, requiring short term solutions, which may inhibit more sustainable solutions and the longer term human resource development agenda. Strategically, the management of change requires top down methods, yet consistent with this is a requirement to generate the capacity for long term change, embedded at the level of the group or individual in the notion of capability.
In order to facilitate this capacity of fostering capability within the working environment “the microculture of the immediate work environment” is crucial(p2). A climate favourable to learning is recognised as significant.
Drawing on Molander (1992) Eraut (1998) indicates that "at every level from the individual to the organisation there is a tension or conflict between that confidence in the resource of knowledge which underpins efficient performance and critical knowledge formation which underpins the capability to change.
Eraut (1998) identifies a triad of confidence, motivation and capability as requirements for learning at work, particularly when capability is perceived as being acquired rather than innate. Learning is situated within the work or practice environment; yet within some clinical settings, I contend, the full complexity of the working environment as an informal and potentially supportive learning context is ill appreciated.
Fox (1996), writing in the context of medical education, advocated learning issues associated with changing practices or adopting innovations as key skills requiring early attention within the medical curriculum. His recommendations were based on the findings that continuing medical education was not necessarily an effective means for changing medical practice. This study focused on the process of learning and change naturally occurring within the lives of physicians. Learning is context dependent, and as an example Fox reported on the need to re-learn basic science within the clinical setting.
Noting implications regarding “evidence based health care” Fox focuses again on forces for change. He points out that “scientific evidence” neglects the complex clinical environment, and the political context. The role of the physician changes in relation to the construction of the health care system.
Parallels exist within other professional groups on development of evidence based approaches.Pam Lomax (1999), in relation to educational inquiry, uses the phrase ‘evidence based professionalism' in order to develop the term ‘evidence’ beyond its current positivistic use by influential educators. According to Lomax, respect for evidence is pivotal to evidence based professionalism, but evidence may be relative rather than reflecting an absolutist position. For Lomax :
evidence is any argument or data I can provide you or you can provide me that claims we make are believable. Evidence is situationally determined. …it is equally important that there is an open mind about what should constitute evidence. In the past there has been a tendency to accept scientific evidence appealing to rational criteria.
Change is ultimately personal. Personal contact is considered as a vital characteristic in making change work, as is the acknowledgement that individuals need to converse about the change in order to make it personally significant. (Fullan)
Change involves unlearning, which may be threatening and requires a supportive environment. Significant educational change (in terms of changes in performance and practice) may only be facilitated through a process of personal development in the context of socialisation. (Fullan)
Cameo:
The precarious nature of the early stages of any innovation process are frequently apparent. At the group meeting two health visitors talk of their activities in visiting the voluntary agency workers at the school where a “Stay and Play” facility is organised (on an experimental basis, as the first stage of a PDSA cycle). Other health visitors are increasingly inquiring about what they are doing, and why.
It has been a slow process from initial, halting steps when it was decided to transfer health visitor activities to another setting. Early discussions explored the possibility of taking their scales, as some sort of badge of office, to the school hall. Initially the health visitors identified themes for each week. This procedure is no longer considered to be necessary. The health visitors no longer need the support of such devices. They are now responding interactively in context. Rather than standing behind the scenes they are actively engaged.
Observations by the health visitors in this naturalistic setting have been illuminating for those involved. The possibility of conducting assessments was raised, and dismissed, because the mechanistic “tick box” approach was perceived to be less valuable than the in depth knowledge gained through observation in such informal settings.
A range of outcomes have been reported:
Mothers are gaining key parenting skills
Health visitors are gaining confidence in adapting their practice
Health visitors are able to anticipate gaps in the service
Assumptions about the user group have been challenged
Isolated parents have been identified
Networks of informal support amongst the parents attending are emerging. Many of the young mums are now increasingly active.
There is increasing demand for the activities.
I wonder about the rich tapestry of the hidden curriculum within the learning environment.
Thus, what I have attempted to highlight in this section is the relationship between learning and the change process, and how these aspects are fostered by personal characteristics but in addition, fostered by critical aspects within the work environment, including the need for social support. The necessity to create the conditions for change and improvement represents a learning outcome from school improvement evaluations, this learning, I contend, is transferable to further learning contexts.
In the next section I indicate a possible direction from which to address shifts in learning perspectives. This draws on themes emerging from the project. More theoretical in nature, it appears to afford a framework to support deeper levels of personal learning around interprofessional issues, historically a problematic area.
Shifting learning perspectives
Learning to adopt new practices entails acknowledging the need for change, and unlearning old patterns of behaviour. It frequently requires a supportive community of practice. In the context of the RIPE project new practices may be explored and identified within interprofessional learning sets using a needs focused approach, primarily within naturally occurring working groups. The focus is on systemic approaches to improvement to the service delivery. It therefore reflects the issues manifest within the NHS changes, and the NHS agenda.