Pract. Dev. Health Care 5(3) 121–123, 2006Copyright © 2006 John Wiley & Sons, Ltd DOI: 10.1002/pdh

Editorial

Strategies for implementation: The need to value complexity

In contemporary health and social care, evidence-based practice, clinical effectiveness and knowledge utilization have become essential foci in the development of person-centred evidence-informed practice. Within these broad strategic agendas, fi nding effective strategies for the implementation of knowledge into practice is a key agenda – one that occupies the minds of policymakers, quality facilitators and researchers. In-deed, in response to such agendas, ‘innovation centres’ are now commonplace in uni-versities with an explicit remit of managing and co-ordinating knowledge translation and implementation strategies. The growth in research into ‘research use’ is signifi cant and there is increasing investment internationally in this new branch of research. More traditional approaches to research utilization assumed that if practitioners were made aware of the defi ciencies in their practice and educated about ‘best practice’ then prac-tice change would occur. However, evidence suggested otherwise and critiques of technical–rational models of knowledge utilization have highlighted the naivety of as-suming that acquired knowledge would lead to changes in practice (see for example Kitson et al., 1998). Implementing evidence and developing practice presents practitio-ners with a number of complex challenges (Rycroft-Malone et al., 2002) not least of which is a health care context that continuously changes.

In order to implement evidence into practice, practice development strategies that have the explicit intent of enabling individuals and teams to change the culture and context of practice to ones that embrace innovation and effectiveness need to be adopted. Such cultures cannot be created by simple input–output models of knowledge implementation, but instead methods that recognize the complexity of health care de-livery systems need to be embraced. Increasingly, this kind of practice development is internationally recognized as being important to the creation of cultures of clinical ef-fectiveness – and not before time, many people would argue. People engaged in practice development facilitation have experienced frustration at the lack of recognition of practice development processes in the ‘parallel universe’ of knowledge utilization. While researchers working in the fi eld of knowledge utilization have been trying to fi nd the ‘magic-bullet’ for translating knowledge into practice, practice development processes have largely gone unrecognized in this agenda. It would be easy to draw upon conspiracy

121Practice Development in Health CarePract. Dev. Health Care 5(3) 121–123, 2006Published online in Wiley InterScience(www.interscience.wiley.com) DOI: 10.1002/pdh.196

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Pract. Dev. Health Care 5(3) 121–123, 2006Copyright © 2006 John Wiley & Sons, Ltd DOI: 10.1002/pdh

theory at this stage; however, it is increasingly clear that the reason for this poor recognition lies with practice development itself.

In the fi rst ever systematic review of the evidence base underpinning practice development, McCormack et al. (2006) found that while many strategies for implement-ing evidence into practice are accounted for in the literature, little systematic evaluation of these strategies has been undertaken. Findings from empirical studies demonstrated a variety of approaches in use to bringing about changes in practice. The review con-cluded that the current literature does not allow for the direct measurement of practice development outcomes arising from specifi c change interventions. Part of the challenge lies in the current lack of published methodological developments in practice develop-ment, with most published studies focusing on describing various ‘batteries’ of methods used to frame the work, including education sessions, training programmes, seminars, refl ective processes, action learning, cognitive skill development, visioning, psychody-namic consultation, quality improvement activities and clinical audit. While methods such as these are described, the evaluation of their use does not correlate the impact of these methods (or any one of these methods) with outcomes achieved.

The complexity of practice development as an activity in itself highlights many diffi culties in systematically evaluating practice development methods. Thus it can be concluded that trying to isolate singular practice development methods in order to de-termine process–outcome relationships is a fl awed strategy given the complex and multifaceted nature of practice development. In order to tease out this issue further, McCormack et al. (2006) identifi ed from the literature and from the fi ndings of tele-phone interviews with practice developers that there is a range of methods common to all practice developments. It is further argued that for practice development to be ef-fective in implementing evidence into practice (including improving practices and generating knowledge from the process) then these methods should shape practice de-velopment methodologies. These essential methods are:

• Agreed ethical processes.

• Stakeholder analysis and agreed ways of engaging stakeholders.

• Person-centredness.

• Values clarifi cation.

• Developing a shared vision.

• Workplace culture analysis.

• Collaboration and participation.

• Developing shared ownership.

• Refl ective learning.

• Methods to facilitate critical refl ection (e.g. action learning).

• High challenge and high support.

• Feedback.

• Knowledge use.

• Process and outcome evaluation.

• Facilitation of transitions.

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Pract. Dev. Health Care 5(3) 121–123, 2006Copyright © 2006 John Wiley & Sons, Ltd DOI: 10.1002/pdh

• Giving space for ideas to fl ourish.

• Dissemination of learning.

• Rewarding success.

While the evidence of the effectiveness of practice development implementation strate-gies is weak in many areas, there is still much to be celebrated. Despite the lack of clarity about methodologies and methods, much has been achieved by those committed to changing practice cultures and improving health care practices. The next era of advancements in practice development should focus on developing methodologies, testing out implementation strategies (methods) and adopting systematic approaches for evaluating processes and outcomes. Embracing this agenda provides practice development with an exciting and challenging future.

ReferencesKitson A, Harvey G, McCormack B (1998). Enabling the implementation of evidence based practice: A

conceptual framework. Quality in Health Care 7: 149–58.Rycroft-Malone J, Kitson A, Harvey G, McCormack B, Seers K, Titchen A, Estabrooks C (2002). Ingredi-

ents for change: Revisiting a conceptual framework. Quality and Safety in Health Care 11(2): 174–80.

McCormack B, Dewar B, Wright J, Garbett R, Harvey G, Ballantine K (2006). A Realist Synthesis of Evi-dence Relating to Practice Development: Final Report to NHS Education for Scotland and NHS Quality Improvement Scotland. Edinburgh: NHS Quality Improvement Scotland, Edinburgh.

Brendan McCormack University of Ulster/Royal Hospitals Trust, Belfast