113Practice Development in Health Care, 3(2) 113–120, 2004 © Whurr Publishers Ltd

Ideas and opinions""Doing practicedevelopment

In this article, I reflect upon my threeyears experience as a practice devel-opment nurse in an inpatient residentialrehabilitation unit for people with mentalhealth problems. Before I begin todescribe my experiences it may be helpfulto provide a brief description of the placewhere I worked. MacMillan Close openedin 1987 as a residential rehabilitationunit following the closure of two hospital-based wards. The Close is a cul-de-sac of12 neo-Georgian houses with threebedrooms in each; these houses incor-porate three non-residential houses forstaff offices and meeting rooms. Onehouse includes a drop-in area forresidents’ use during the day. There are 27residents at any one time, with approxi-mately 30 staff comprising mostlyqualified mental health nurses workingon 24-hour rotation. For further details ofMacMillan Close see Stickley and Leng(2003).

Having worked on the unit for fiveyears, by 2000 I was a Deputy Managerand co-ordinated one of the three teamson the unit. At this time our local Schoolof Nursing advertised for a part-time

teacher/practitioner. I was successful inmy application and this meant that I wasto work three days per week within theSchool and two days in practice. It wouldhave been unrealistic to expect me tocontinue my co-ordinating role on onlytwo days per week so our ServiceManager gave me the opportunity towork on practice development during mytwo days in practice.

Simultaneous with my starting thisnewly developed role the unit began theprocess of working towards practicedevelopment unit accreditation with theUniversity of Leeds. This process gave mea structure for the work. In order to satisfythe essential criteria for accreditation wehad to demonstrate that we had activelyachieved certain conditions relating topartnership working with service usersand educators: evidence of creativity andinnovation, and a genuine commitmentto bringing about change for the good. Inorder to achieve these aims we alsoneeded to demonstrate a shared visionand effective leadership. We created ourown objectives to help focus ourapproach to practice development and weagreed on the following areas:

" improvement in the experience ofservice users and carers

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" improvement in the experience ofstaff who work to provide the services

" development of the foundations of a system that allows us to assess ourclinical effectiveness.

It is all too easy to imagine a practicedevelopment initiative to be introduced‘top down’ from the agenda of managers.We quickly realized that in order forpractice development to be meaningfuland real, it needed to be owned by thestaff and residents. With this in mind Ideliberately developed my role to retain a‘grass roots’ feel about it. This was largelyachieved by spending time with people.Much clinical time is often spent ‘fire-fighting’ or in meetings. I deliberatelymade a point of talking with all staff,whatever their grade or status within theteam. Staff were encouraged to becomeinvolved in a number of the practicedevelopment initiatives. The rest of thisarticle is an account of my grass rootsworking with the team and residents ofMacMillan Close and its sister units.Although I will focus upon a few of theactivities and groups that have been setup, it is necessary to point out that manypeople have been involved in a widenumber of activities and groups over theyears. The activities and groups I focusupon here probably reflect the ones withwhich I have had most involvement.

We quickly realized that inorder for practice devel-opment to be meaningful andreal, it needed to be owned bythe staff and residents.

Evidence-basedpractice projects

At the same time I commenced my role,the trust implemented a programme ofdeveloping an evidence-based practiceinitiative. I was a part of the pilot studythat introduced the model at team level.My first impression was that this was anew model of practice being introduced‘top down’ by the management. With thisin mind, it was important to acquaintmyself with the benefits of the initiativeso as not to appear managerial and ‘topdown’ in my approach to staff. Havingworked on the unit as a nurse for fiveyears, I did not want to feel removed fromthe workings of the team; neither did Iwish to be considered by others assomehow aloof through the definition ofmy role. How I decided to implement thisstrategy therefore was more about anopportunity to celebrate good practicerather than ‘We must do this becausewe’ve been told we must do this’. Theteam has regular times set aside forpractice development. We used some ofthis time to mind-map the areas ofpractice we would like to focus upon. Anumber of topics were identified andincluded the following areas: crisis inter-vention; the therapeutic relationship;services for women; group working; therole and function of residential rehabili-tation; and mental health and the arts.Small work groups were set up to followthis evidence-based practice cycle (CSAP1999) (Figure 1).

Part of the ethos of the team’spractice development was to give all staffan opportunity to become a part of theinitiatives, irrespective of their grade ordiscipline. Whilst staff were encouraged

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to be involved in at least one project,nobody was made to feel that it was aduty or obligation. There were practicalimplications for implementing thestrategy, not least ensuring that staff hadaccess to the internet and the relevantdatabases for searching for best evidencewithin the nursing and healthcare liter-ature. Some staff were pleased to be given‘permission’ to have time set aside forresearching and studying their chosenarea. Others felt intimidated by theprospect of accessing computertechnology. I made a point of meetingwith leaders of each of the evidence-based practice projects and offeredsupport with researching or writing uptheir projects. We would also discuss theblocks and opportunities to imple-menting their project as well as thepotential levers to shift the blocks. Theprocess of finding out the best evidenceincluded accounting for our own practiceas well as researching the literature. Staffwere encouraged to reflect upon whatthey and the team have done well. Part of

the object of the exercise was to help staffto feel valued and to encourage them tocelebrate what they do well. During thistime a number of focus groups and inter-views were conducted among theresidents of our service. Ultimately, it wasintended that through this process ofestablishing service user views we wouldbe able to monitor the extent to whichour practice had developed, hopefully forthe good of client care in our unit.

Art developmentgroup

Art activity has always been popular withour client group. It has also been a focusof practice development. For a fullerdescription of this you may like to look atCoulson and Stickley (2002). Wedecided to set up an art developmentgroup for staff and clients with an interestin promoting art activities within thetrust. It was thought to open out themeetings to local artists and organizationswho have an interest in working with

Ideas and opinions

Figure 1. The evidence-based practice cycle (CSAP 1999).

Asking the question

Finding the evidence

Acting on the evidence

Evaluation andreflection

Appraising and interpreting evidence

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people with mental health problems.Since its inception, the group hasachieved much:

" Ongoing support and encouragementfor practitioners wanting to workwith art activities in their units.

" Developing strategic proposals toattract funding for arts activities.

" Sharing practice and ideas." Creating partnership projects

between statutory and voluntaryworkers and service users; these haveincluded workshop days held in a citycentre venue.

" Commissioning service user artwork for trust premises.

" Conference presentations." Training days for using art in mental

health practice.

Implementing and maintaining thisgroup has been enjoyable, hard work andsatisfies parts of Standard 1 of theNational Service Framework for MentalHealth (DoH 1999). Art activities forexcluded and disadvantaged people arealso specifically called for in theDepartment of Health mental healthpromotion document Making it Happen(DoH 2001) and The Arts Matter: the ArtsCouncil’s Annual Review (Arts Council2002). One difficulty with the group hasbeen sustaining continued input fromservice users. Although some service usershave enjoyed the opportunity tocontribute to the development of creativeactivities in mental healthcare provision,we have questioned the ethics of invitingpeople to these meetings without beingable to offer payment for their time (thegroup has never had a budget of its own).The issue of payment for service users

affects any development and planningactivity that wishes to involve serviceusers. Some of the milestones of theinitiative with regards to client-centredworking include:

" a growth in the number of art activ-ities throughout the trust

" numerous service user art exhibitions,sales of work and commissions

" service user art displayed in theentrances to three trust hospitals

" drama productions leading to videorecording and public performance.

The development of arts activities inmental healthcare is on the increase;however, there is still little in the way ofstatutory funding for major initiatives andresearch into this area is in its infancy.

Social inclusion workgroup

A social inclusion work group was set upin one of the residential units. Thepurpose of the group is to promote socialinclusion for the residents. The group ismade up of staff and residents. At thetime of writing this has been meetingmonthly for two years. One of the activ-ities of the group is to analyse the localcommunity by walking around the areataking note of potential resources. Weinvestigate libraries, community centres,GP surgeries, pubs, churches and clubs,etc. We then conduct a SWOT(Strengths, Weaknesses, Opportunitiesand Threats) analysis of these resources,as suggested by Bates (2002).Connections are made with the localcommunity groups that have beenidentified to facilitate education,

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employment and leisure. We have hadvisits from the community police officeras well as the local clergy. What we aretrying to achieve is to help peopletowards a sense of citizenship andbelonging to the local community. Wewould, however, echo the sentiments ofLiz Sayce when she claims that we have along way to go yet for psychiatric patientsto be classed as citizens (Sayce 2000).Part of the success of this group is that wemeet in the residents’ lounge area and payresidents a small sum for attendingmeetings, which do not have a fixedagenda. At times we have spent some ofthe meeting discussing residents’ experi-ences of what it was like in the oldasylums. Although nobody advocates areturn to the asylum era, there is a senseof loss among those who benefited fromthe sense of community that that the oldhospitals provided.

Research and auditIn the introduction to this article Ioutlined the objectives we set ourselvesprior to practice development unitaccreditation. These included:improvement in the experience of serviceusers and carers; and improvement in theexperience of staff who work to providethe services and development of thefoundations of a system which allows usto assess our clinical effectiveness. Thiskind of framework provides a structure forimplementing research and auditprocesses to address issues of practicedevelopment. We decided from theoutset that it was essential for staff andresidents to be able to speak out abouttheir thoughts and feelings about thedelivery of care. These opportunities

came for both public and more privateconsultations. Two audits were imple-mented, one for staff and the other forresidents. I designed and conducted thestaff audit, but for the resident audit wecommissioned a local service user groupto implement a programme of user-focused monitoring, as developed by theSainsbury Centre for Mental Health(SCMH 1997). This group was calledService User Monitoring Service(SUMS) but has more recently changedits name to ‘Making Waves’. From ourexperience, user-focused monitoring is anexcellent way of ascertaining the views ofservice users.

For the resident audit wecommissioned a local serviceuser group to implement aprogramme of user-focusedmonitoring, as developed bythe Sainsbury Centre forMental Health.

The main principle behind the process isthat it is conducted by service usersthemselves. The trust manager negotiateda fee with the SUMS group, which wasgiven a remit to conduct interviews withthe residents of our service. SUMS inter-viewers had previously received trainingfrom the Sainsbury Centre. The serviceusers in SUMS were paid for their workand residents were offered a small fee forbeing interviewed. Whilst residents werefairly complimentary of the service andstaff attitudes, a number of unexpectedcriticisms emerged, including the factthat a number of people could not nametheir key worker or articulate what was in

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their care plans. Each point that came outof the subsequent SUMS report became afocus for a development action plan. Theimplementation of the action plan wasmonitored in the succeeding months. Twoyears on, it is high time to audit againstthis report; however, it has been difficultto secure funding for the commissioningof further user-focused monitoring.

The results from the staff audit wereencouraging for the management group.Generally, people were happy with theirworking conditions and morale was fairlyhigh. It is interesting to note that duringthe period of working towards practicedevelopment unit accreditation, staffabsence due to sickness remained excep-tionally low and has in fact halved fromwhat it was previously. In these days ofhigh attrition rates for newly qualifiednurses, MacMillan Close has excelled instaff retention. The negative elements ofthe staff audit were related to theenvironment and issues of communi-cation between the staff group. Thesehave been attended to, and improvementsmade, although ongoing audit is necessaryto ensure these improvements have beensustained.

Writing up and sharingpractice

Dissemination is an importantcomponent of practice development.With this in mind we initiated a dissemi-nation work group who in turn developeda dissemination strategy. It is in this areawhere my working for the university hasproved invaluable. It is our academiccolleagues who are most used topublishing and presenting at conferences.The importance of the partnership

between practice and academia cannot beoveremphasized. Practitioners need theacademics to help with researching,writing and presentation skills; theacademics need practitioners to give themsomething real to be involved with.Historically, the theory–practice gap isexemplified by the relationship betweenpractitioners and academics. Practicedevelopment provides a foundation forbreaking down these barriers and preju-dices and an opportunity for meaningfulpartnership working. To date our practicedevelopment initiatives have produced anumber of articles relating to thefollowing subjects:

" residential rehabilitation (Stickleyand Leng 2003)

" team and group working (Howard 2002; Whittaker and Stickley 2003)

" social inclusion (Eve 2002; Shaw et al. in press)

" the women’s service (Mallon 2001; Owen et al. 2003)

" the crisis service (Stones and Stickley2001)

" art development (Coulson and Stickley 2002)

and, in addition, seven conferencepresentations. One acknowledgedweakness in our dissemination activities isthe lack of service user involvement. Aswell as the high-profile examples ofdissemination, there has been a realcommitment to share our practice locally,especially within the wider trust. We setup monthly practice development forumswhere people present their work to fellowstaff. We are pleased to say that this hasincluded service users giving theirperspective. The trust also has a

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newsletter that we regularly target fordissemination.

Practice development pro-vides a foundation for break-ing down these barriers andprejudices and an opportunityfor meaningful partnershipworking.

Service userinvolvement

The whole notion of involving serviceusers needs to be questioned. Althoughthere is a growing literature relating tothis subject, in practice I am constantlyfeeling that everything we attempt istokenistic unless involvement includeshanding over power. This may have beenachieved to some extent through theservice user monitoring we commis-sioned. The issue of payments to serviceusers is key to some of the power issues.How can we justifiably expect serviceusers to work in equal partnership withservice providers when, at grass rootslevel, nurses and doctors have legalauthority over clients and patients?Similarly, our clients and patients are veryoften living in poverty. Staff salaries maybe low relative to the private sector;however, compared with living onbenefits, staff may be perceived as wealthyby those who use our services.

Final reflectionsThe notion of practice development mayappear too abstract for the uninitiated.

Here, I have given an account of my rolein a simple and straightforward way;practice development, however, is neithersimple nor straightforward. Throughoutthe two-year period I performed the role, Iwas impressed by the willingness of practi-tioners to work towards improving theirpractice. However, there are a number ofblocks to effective practice development.For some, sitting in meetings anddiscussing practice development initia-tives is frustrating and not valued,‘Shouldn’t we just be spending more timewith the residents?’ was one argument; ‘Is itnot better to do rather than talk about doing?’was another. For others, the implemen-tation of the evidence-based practicestrategy felt threatening; after all, whereare the randomized controlled trialsproviding evidence of the need to sit anddrink tea with a distressed person? Theultimate test of practice developmentmust surely be ‘Has the practice on the unitdeveloped for the good of the residents andstaff?’ It is the results of these questionsthat should be the litmus for determiningsuccess.

AcknowledgementThe author would like to thank his mentor, BevJohnson, for help in writing this article, and heacknowledges her commitment to developingpractice in Nottingham.

ReferencesArts Council. The Arts Matter: Arts Council of

England Annual Review. London: ArtsCouncil, 2000.

Bates P (Ed.). Working for Inclusion. London:Sainsbury Centre for Mental HealthPublications, 2002.

Critical Skills Appraisal Programme. Evidence-based Health Care. London: CSAP and HealCare Libraries Unit, 1999.

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Coulson P, Stickley T. Finding a voice–artisticexpression and practice development. PracticeDevelopment in Health Care 2002; 1: 85–97.

Department of Health. National ServiceFramework for Mental Health. London:HMSO, 1999.

Department of Health. Making It Happen–A Guideto Delivering Mental Health Promotion.London: DoH Publications, 2001.

Eve J. Opportunity knocks. Open Mind 2002; 118:11.

Howard V. One of the gang. Mental HealthPractice 2002; 6: 6–11.

Mallon S. Therapeutic benefits of a women-onlyenvironment. Nursing Times 2001; 97: 40–41.

Owen S, Jones C, Mallon S. A women’s network.Mental Health Practice 2003; 6: 12–17.

Sayce L. From Psychiatric Patient to Citizen.Overcoming Discrimination and SocialExclusion. London: MacMillan, 2000.

Shaw R, Stickley T, Davies K. Working together.

Journal of Psychiatric and Mental HealthNursing, in press.

Sainsbury Centre for Mental Health. Users’ Voices.London: SCMH, 1999. (www.scmh.org.uk)

Stickley T, Leng M. Residential rehabilitation andthe modern agenda. Mental Health Practice2003; 7: 26–31.

Stones S, Stickley T. Developing a crisis service atMacMillan Close. Mental Health Practice2001; 4: 14–18.

Whittaker D, Stickley T. Happy families: expressedemotions in teams. Mental Health Practice2003; 6: 34–37.

Address correspondence to: TheodoreStickley, Lecturer in Mental Health, Schoolof Nursing, University of Nottingham,Duncan MacMillan House, Porchester Road,Mapperley, Nottingham NG3 6AA (E-mail:theo.stickley@nottingham.ac.uk).

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