Improving the quality of patient care through a systemic approach to emancipatory practice development

© 2006 Dr. Catherine M. BarrettThis study used an emancipatory action research method to explore the significance of practice development as a systemic strategy to improve patient-centred care in a Cardiothoracic Surgical (CTS) Unit. The need for the study arose from recognition that the increasing levels of patient injury and death in healthcare requires a patient-centred and systemic response. The study presents practice development as one such response to engage the whole system of care in improvements and ensure patient-centred care. The study involved the development, implementation and evaluation of a Practice Development Program. An emancipatory action research methodology was used to maximise the participation of staff in the Program and to promote sustainable change. This methodology was also considered suitable as it parallels emancipatory practice development. The Program involved three action research cycles to reflect on patient care in the CTS Unit and make improvements. The first program cycle involved an evaluation of care using an Empowerment Evaluation approach (Fetterman, 2005). This was then complemented with patient and staff interviews and surveys. The evaluation provided the opportunity for staff to see and understand their practice differently and created the momentum for practice change. The second program cycle began with a staff ballot on the value of continuing the Program which identified that ninety percent of staff supported maintaining the Program. At the end of the cycle an evaluation of the Program, to determine opportunities to consolidate successful outcomes, was carried out. This was supported by the development of a local 'Change Achievement Map' or checklist of requirements for successful, systemic practice development. The Map highlighted the challenges involved in implementing a systemic approach and the opportunities to strengthen the Program. Throughout the second program cycle staff continued practice change activities, with 44 staff involved in coordinating projects to improve patient care. As such, the Program established a culture of clinical governance, or held staff accountable for improvements. While staff were held accountable they were also supported to take ownership of change, make sense of it and to work across disciplines and departments to enhance patient care. The third program cycle began with an evaluation of care (similar to the first program cycle) to stimulate a further 12 months of practice development. With the increased ownership that occurred over the course of the Program, staff took more active roles in the evaluation, including facilitating a number of Evaluation Workshops and conducting patient interviews and surveys. The increased level of staff participation led to new insights about the emotional labour of care and the challenges this presented to enhancing patient-centred care. This Program cycle also explored the efforts of staff to sustain the Program beyond the involvement of the External Facilitator. The study involved reflection on the characteristics of practice development and the construction of propositions, or critical theorem, relating to the effects of the Program and how practice development occurred. In addition, propositions about the systemic characteristics of practice development were explored and a new, systemic model of practice development is presented. The study concludes that a systemic approach to practice development is an effective strategy to improve patient care