Using reflective practice processes to identify practice change issues in an aged care service

Using reflective practiceprocesses to identify practicechange issues in an aged careserviceK. Walsh, M. McAllister and A. Morgan

This paper reports on a reflective process used to identify areas for practice change as oneelement of a large practice development project that is currently being implemented in a

large metropolitan psychiatric hospital. The paper describes a stepwise process of group andindividual reflection on practice which was successful in helping clinicians identify areas forpractice change and motivate them to plan and implement client centred change. The

process described here also shows that reflection itself is insufficient to bring about changeand that structures must be developed to act as the scaffolding to support the changes

identified by the reflection on practice. �c 2002 Elsevier Science Ltd. All rights reserved.

Introduction

This paper reports on a reflective process usedto identify areas for practice change as oneelement of a large practice development projectthat is currently being implemented in a largemetropolitan psychiatric hospital. The paperwill describe a method of group and individualreflection on practice which was successful inhelping clinicians identify areas for practicechange and motivate them to plan andimplement client centred change.

History of the project

Before discussing the reflective practiceprocesses used in the project, a brief history ofthe project will be outlined to put the reflectivepractice processes in context of the largerpractice development plan.

In early 2001 discussions took place betweenthe Chief Executive Officer of Royal AdelaideHospital and academic staff of the Departmentof Clinical Nursing at The University ofAdelaide about the possibilities of designing

and implementing a practice developmentproject on Glenside Hospital Campus, now apart of the greater Royal Adelaide HospitalHealth Service.

Royal Adelaide Hospital is committed tocontinuing practice improvement and wishedto develop a model that could be utilised in avariety of settings. It was therefore decided todesign a clinician driven practice developmentprogram and implement it across the GlensideCampus over a three year period. Glensidehospital is comprised of some 19 wards. It wasnot feasible, given the resources available, tocommence practice development across theentire campus simultaneously. The campus isdivided into a number of distinct areascomprised of groups of wards such as‘‘Extended Care’’, ‘‘Forensic Mental HealthServices’’, ‘‘Services for Older People’’, and soon. It was decided to start the project in one ofthese distinct areas.

The decision as to where to commence theproject rested on a number of issues. Ideally thearea to start should comprise a number ofwards that saw themselves as a service area.

230 Nurse Education in Practice (2002) 2, 230–236 1471-5953/02/$ - see front matter �c 2002 Elsevier Science Ltd. All rights reserved.doi:10.1016/S1471-5953(02)00023-9, available online at http://www.idealibrary.com on

Article

K. WalshRPN RGNBNurs PhD,Department ofClinical Nursing,University ofAdelaide andPracticeDevelopmentCoordinator,Royal AdelaideHospital, GlensideCampus, PO Box17, Eastwood, SA5063, Australia.Tel.: +61-8-83031448;E-mail: ken.walsh@adelaide. edu.au

M. McAllisterRN RPN Dip AppSci, BA, MEd, Ed D,School of Nursing,Griffith University,Nathan Campus,NathanQueensland,Australia.

A. MorganRN RPN DipAppSciPsych NursingGrad Dip EdGrad Dip ArtsMSocSc, StaffDevelopmentDepartment,Royal AdelaideHospital,Adelaide, SA,Australia.

(Requests foroffprints to KW)

Manuscriptaccepted:8 May 2002

mail to: @adelaide

There needed to be a diversity of patients sothat the model could be implemented andrefined in a variety of settings. Also the areaneeded to be large enough that if the modelbrought the desired outcomes there would betangible benefits to the health service.Eventually it was decided to commence theproject in Services for Older People. Servicesfor Older People consists of five wards withattendant community services. It includes twoacute admission wards; a medical centre andtwo long stay dementia units. In this way thepractice development plan could beimplemented and refined and the staff ofServices for Older People would then assist inrolling out the practice development projectacross the campus. Hence the impetus for theproject would not rely on any one person butwould more likely be self-sustaining andwould be truly peer driven.

Practice development

Practice development is a phrase that isbecoming more common in health services inAustralia and the UK. It has been defined as

. . .a continuing process of improvementtowards increased effectiveness inperson-centred care, through the enablingof nurses and health care teams totransform the culture and context of care.It is enabled and supported by facilitatorscommitted to a systematic, rigorous, andcontinuous process of emancipatorychange. (McCormack et al., 1999, p. 256)

Practice development is therefore asystematic process aiming to bring aboutlasting change. For lasting change to take placethe process needs to be collaborative and beowned by the clinicians involved. It takes intoconsideration factors that are both internal andexternal to the organisation within which thechange is to take place. In this way practicedevelopment is responsive to the political,economic, and clinical factors which impactupon practice.

According to McCormack et al. (1999) thereare two main purposes of practicedevelopment. These are, to improve patientcare and to transform the context in which caretakes place.

Reflection in practice development

The idea of using reflective practice processesin nursing is not new and is widely espousedin the nursing literature (Usher et al. 2001). Ithas been used to help nurses problem solve,think critically, and make safe clinical decisions(Van-Horn 2000). It has been used in a varietyof settings from nursing education to clinicalsupervision (Todd & Freshwater 1999). As withthis project, it has been utilised as a keycomponent in practice development (Graham2000, McCormack & Hopkins 1995).

Reflection has a variety of definitions.However, for the purposes of this paper it canbe defined as

The process of internally examining andexploring an issue of concern, triggered byan experience, which creates and clarifiesmeaning in terms of self, and whichresults in a changed conceptualperspective (Boyd & Fales 1983).

This is not to say that reflection is only anintrospective process. It can be a transformingprocess in terms of self understanding (Glaze2001) but also has the capacity to shiftindividual knowledge from the private to thepublic domain (Clouder 2000) and thereforehas the ability to influence practice.

According to Cooney (1999) reflection bringsto the surface, that which is unconscious, takenfor granted, covered, hidden, or obscured. Itmakes theory explicit, and invisible knowledgevisible. It allows the person to uncover manyfactors influencing their behaviour and canlead to insight and therefore to change. Insightmight not necessarily lead to change, but it isthe necessary first step (Cooney 1999). Thereflective process described here wasdeliberately designed to move insight andknowledge from the private to the publicdomain, to move thinking from the technical tothe critical and to be the first step in bringingabout practice change.

Development of the proposal

A proposal was developed to design andimplement a practice development project onthe Glenside Campus as an adjunct to otherchanges aimed at improving clinical practices

Practice change issues in an aged care service

�c 2002 Elsevier Science Ltd. All rights reserved. Nurse Education in Practice (2002) 2, 230–236 231

and client outcomes. It was agreed that a seniorlecturer, would head the project and would besupported by the Staff DevelopmentDepartment of the RAH.

The Model to be implemented was adaptedfrom the work of Ward et al. (1998). It consistsof five phases (see Table 1).

Establishment of practicechange groups

Pivotal to the proposal is the formation of wardbased practice change groups made up ofmultidisciplinary clinicians, who wouldinvestigate current practice and then design andimplement practice change. It is the reflectivepractice process used to identify practice changeissues which is the subject of this paper.

Following the orientation phase of thePractice Development Plan, volunteers werecalled to form small groups in the wards(approximately 5–7 people in each ward). Thisdid not mean that others could not have inputbut that these individuals would be the driversof practice change in their wards and liaise withother staff, clients, and carers. The names of thepeople in the groups were distributed to all staffvia anewsletter so that everyonewas awarewithwhom they could exchange information.

Following the formation of the groups,education sessions were conducted with each

group separately on the topics of practicedevelopment, practice change, and reflectivepractice.

Reflective practice processesand action change

A stepwise process of action change wasadapted from the work of Binnie and Titchen(1999) (see Table 2).

Identifying and planning practicechange

What follows is a detailed account of thereflective processes utilised in the planningphase of action change to identify areas ofpractice that were to be the focus for change.

Practice change identification

The planning phase was conducted with eachward group separately over a period of threeweeks and consisted of two half-day groupsessions separated by a period of one week.

Week one: preparation for change

This first half-day group meeting consisted ofpractice change groups of up to seven

Table 1 Practice development plan

Phase IOrientationThe orientation phase involves orientating staff to the concept of practice development, gathering baseline data,outlining the model to be used, and making modifications based on staff feedback

Phase IIPreparation for changeThis phase builds upon the preliminary work undertaken in phase I. The focus for this phase is to prepare thoseinvolved and to develop a systematic plan for change

Phase IIIProcess of change and its evaluationIn this phase the implementation of the changes, designed in phase II, takes place. It also includes evaluating theeffects of change and supporting staff undertaking change

Phase IVComparative analysisThis phase involves the measurement of the changes implemented including qualitative measures such as staff andclient interviews as well as quantitative measures such as re-auditing

Phase VRefining change and setting new goalsThis phase builds upon the feedback gathered in phase IV and sets new goals to be achieved as well as streamliningthe processes used in the previous phases


232 Nurse Education in Practice (2002) 2, 230–236 �c 2002 Elsevier Science Ltd. All rights reserved.

members. Groups were held separately foreach ward and consisted of registered nurses ofvarious levels, enrolled nurses, medical andallied health staff, although the groupspredominantly consisted of nurses.

The first part of the session was dedicated toeducation about practice development, actionchange, and reflective practice. The group wasalso given time to develop a set of groupnorms. The norms the groups decided uponwere items such as, every member has an equalsay despite their profession or rank, ademocratic process will be used to decide theareas targeted for practice change, and so on.Interestingly, the group norms developed byeach group were very similar. Group memberswere also provided with readings on reflectivepractice and practice development.

The next part of the session was devoted to adiscussion of the ageing process from a personalor existential perspective. Usher et al. (2001)make the point that reflection can occur at anumber of levels from the technical to thecritical. The use of poetry and story telling was adeliberate attempt to move the reflectiveprocess away from the purely technical. One ofthe authors spent oneweekworking as an RN inthe wards of Services for Older People. Ontalking to the nurses about their work it becameapparent that to a large degree that they lookedupon their work in a purely technical, taskorientated way. Staff therefore had difficulty inseeing practice from any other perspective or

seeing how practice could be different. We feltthat given this situation it was necessary tomove the participants away from the technicaland task orientated aspects of their work beforeasking them to reflect upon it. Through the useof story telling and poetry clinicians weremoved out of their role of ‘‘health professional’’and into the roles of ageing humans, daughteror son of ageing parents, and potential aged careconsumer. Participants were also encouraged totalk about their personal experiences of ageing.Theywere then asked to reflect uponwhether ornot the persons in their care had similarexperiences of ageing to those they had justidentified. With each group an animateddiscussion of these issues ensued. Most groupscame to the conclusion that there is a part of usthat lives outside of time as it were. Most of thetime we are not conscious of our age and reactand feel towards things in our environment aswe always have. As one participant put it,‘‘inside my head I am still only twenty five’’.

This process was a prelude to asking theparticipants to reflect upon a number ofquestions. These questions were:

What are the characteristics of a good agedcare unit?

What would I like to be assured of if I wereadmitted to an aged care facility?

What would I like to be assured of if arelative were admitted to an aged care facility?

What are the characteristics of a good agedcare practitioner?

Table 2 Action change

Planning phaseThis phase consists of a ‘‘reconnaissance’’ of practice through observation and reflection; practice changeidentification; audits of current practice and the development of an action hypothesis. The practice changesproposed are examined for compatibility with the organisational and national standards and refined as necessary

Action phaseIn this phase the changes agreed by consensus with ward staff and management are initiated

Observation phaseThis phase consists of a re-audit of practice and outcome measures. The new practices are examined for theireffectiveness and the degree to which they have been implemented

Reflection phaseThe findings of the observation phase are reflected upon including the degree to which the action hypothesis hasbeen supported. In the light of these reflections the action plan is refined if necessary and changes are enshrined inpolicy

Phase VRefining change and setting new goalsThis phase builds upon the feedback gathered in phase IV and sets new goals to be achieved as well as streamlinesprocesses used in the previous phases.

Adapted from Binnie and Titchen (1999), p. 41.



The group discussed each question and theanswers were written on a white board. Theanswers were interesting and surprised thegroup. They stated that they would want suchthings as freedom to get up when they chose, togo outside, to have visitors when they liked, tohave a glass of wine or beer with meals if theychose. To be treated with dignity and to havedifficult behaviour understood as havingmeaning, to get up a 2 am if they wishedprovided they were not disturbing anyone else.

Working with Goethe’s principle of ‘‘I knowwhat I believe when I hear myself talk’’ (Miller1983) such answers had the effect of bringingabout a cognitive dissonance and a motivationfor change (most of what they said they wantedfor themselves did not occur in the wards inwhich they worked). This is in contrast to ‘‘topdown’’ approaches to change where clinicians,consumers, and carers will often resist changebecause it is imposed and they do not feel anysense of ownership or inclusion in the process.These participants had come to their ownrealisation that their work environments didnot meet their own expectations as consumersor carers.

Week two: reflection in practice

Each participant was given a summary of thegroup reflections upon the questions posedabove. The participants were then asked to goback to work in their ward for one week andreflect upon what had been discussed and notewhat they uncovered. They were asked toapproach their ward as if they were working init for the first time. They were also asked towrite their reflections on the four questions wehad discussed in their work books; what struckthem when they returned to work, what hadthey failed to see before. It was made clear thatthey would not be expected to show thesenotes to anyone else.

They were asked to try not to be subsumedback into the persona of ‘‘health professional’’but to endeavour to look at the workenvironment through new eyes. Perhaps likesomeone from another planet—to questiontaken for granted assumptions and to ‘‘see thewood for the trees’’. By way of example theparticipants were asked to describe, as if they

were an alien from another planet, thedominant form of transport used on earth. Thedescription that emerged can be summarisedas follows:

On earth the dominant mode of transportis the Car, a 1–2 ton metal object which isdriven in opposite directions with closingspeeds of up to 200 km per hour with theonly thing separating these missiles beinga white line painted upon the flattenedplanet surface on which they drive. Thereis no guidance system and humans relyupon their (fallible) judgement to guidethe cars along the road. The result is thatthere are many crashes and thousands ofhumans die each year in accidents.

Whilst humorous, this exercise helped theparticipants understand what was being askedof them in terms of reflecting on their workenvironment.

During this time two of the authors maderegular visits to the wards to remind theparticipants that this week they should try toview themselves as aliens in their wards.

Week three: reflection on practice

One week later the group met again and sharedtheir reflections. It became apparent that theyhad indeed seen their practice environmentanew. The taken for granted had becomeproblematic. Some of the participants wereclearly moved by the experience of suddenlyseeing the ‘‘the wood for the trees’’ and maderemarks such as ‘‘I have worked there for yearsand never noticed it before’’.

As before, their reflections were written on awhiteboard. It became obvious that thereflections fell into two categories. Thereflections were either a principle or a practice.If the participants gave an example of aprinciple then a practice was also asked for andvice versa. For example one participant saidthat sometimes residents were given vitamised(pureed) meals whether or not they neededsuch a diet. This was categorised as a practice.The participant was then asked for the principlethat should inform such a practice. The answershe gave was that residents’ individual needsshould be respected and met—they deserved



individualised care. In this way the whiteboardquickly filled with a list of guiding principlesand a list of practices that the participantsbelieved needed change. At the completion ofthis process a number of themes emerged. Theparticipants then voted on which of thedominant themes should form the basis of thefirst practice change project.

The themes for the five wards wereremarkably similar in that they tended torevolve around the notions of individualisedcare, building partnerships with consumers,and carers or a combination of the two.

Interestingly, the staff of the ward that hadbeen criticised by carers found itself seeing theenvironment anew and elected to makepartnerships with carers their area of change. Award with a task orientated approach to caredelivery decided to implement primarynursing. An admission ward decided toindividualise its admission procedures andinvolve families more in the admission process.

The change projects

The practices identified as needing changevaried from ward to ward as did the strategiesto bring these changes about. Once the broadarea for practice change was identified theparticipants went back to their wards anddiscussed practice change strategies with theother staff. A ward-based meeting wasorganised with each practice change group.This meeting was attended by two of theauthors who asked a series of questions in aneffort to identify and develop practice changestrategies. For example, one of the changegroups identified individualised care as thebroad area for practice development. Thequestion was therefore asked of them, ‘‘If wewere to wave a magic wand and turn this wardinto the world’s best ward for the delivery ofindividualised care, what would we see thatwas different?’’ The following is an example ofsome of the staff responses to this question:

• All clients would have individualised careplans that were actually followed.

• Each client would have an individualbiography written in their files whichincluded information ranging from theirformer occupation to how they like their tea.

• Staff would be less task orientated andthe day would be structured aroundthe needs of the clients.

• There would be a good rapport betweenstaff and relatives and relatives would beincluded in the planning of care.

It was suggested to staff that what they hadin fact begun to develop was a list of outcomemeasures with which to gauge the success oftheir plans and that the next step was to refinethese and devise a strategy to bring about thepractice changes. This ward subsequentlydecided to implement a system of primarynursing.

Each ward has gone through this exerciseand is currently planning the implementationof practice change using a variety of evaluationmeasures and practice change strategies.

Evaluation of the reflectivepractice process

The success of the reflective process describedcan be judged from the fact that each wardgroup chose an area for practice change and allbut one of the five wards have commencedcollecting baseline data prior to theimplementation of changes. The feedback fromthe participants was that they felt the processwas a fair one in which the group normsensured that all participants had theopportunity for equal input. The health servicemanagement was pleased with the areasidentified for practice change as these were inkeeping with national and local standards forthe provision of mental health services.

However, there were some difficulties thatarose following the reflective process describedabove. Whilst these difficulties are not directlyrelated to the reflective process used, they dohighlight the importance of building thesupportive structures necessary for thereflective process to be translated into action.The main difficulty was that on return to thewards some groups found it difficult tomaintain a momentum for change. This wouldappear to be due to two main factors:

1. the process used to identify a leader in eachgroup who would take responsibility fororganising meetings of the group andfacilitating the work of the group;



2. the messy reality of practice which made itdifficult to organise ward-based groupmeetings to further the work of the group.

The process used to identify group leaderswho would take responsibility for organisingmeetings and liasing with the practicedevelopment coordinators was a democraticone whereby each group chose their ownleader/representative. The wards where therepresentative chosen also had some authoritywithin the ward structure fared the best inorganising meetings and keeping the projectmoving. The ward Clinical Nurse Consultantelected to be an active member of the changegroup in only two of the five groups. The otherthree Clinical Nurse Consultants, whilstsupportive of the practice development process,had decided to encourage other team membersto be involved. Following the difficultiesexperienced in keeping up the momentum forchange, the CNCs were recruited as activemembers of the practice change groups and thesituation improved. This shows the value ofactive leadership in practice change processes.

Many groups found it difficult to meet anddiscuss the work of the group because of thedifficulties of finding time in the busy wardschedule and the vagaries of the ward rostersystem, sick leave, and annual leave. Onceagain this situation has resolved to some extentdue to the active intervention of the area nursemanager and the CNCs. Also some of thegroups have recruited new members so that ateach meeting either a group member or a proxyis present.

Conclusion

Using reflective processes has been an integraland important component of practicedevelopment in this setting. It has enabledclinicians to see anew the environment inwhich they work and envisage how it could bedifferent. This process has been a powerful onebecause it has led to insight. The changes havebeen identified and instigated by the cliniciansthemselves rather than being imposed fromthe outside. This has led to feelings ofempowerment amongst the staff and a sense ofownership of the change process. The processdescribed here also shows that reflection itselfis insufficient to bring about change and that

structures must be developed to act as thescaffolding to support the changes identifiedby the reflection on practice.

Acknowledgements

The Authors would like to acknowledge thestaff of Mental Health Services for OlderPeople for their support of the project,especially those involved in the practice changegroups. Thanks are also due to Ms RoslynStreet for her support and leadership and toMs Mary Pomeroy for her assistance withrostering of staff.

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Using reflective practice processes to identify practice change issues in an aged care service