base being used (Liberati et al. 2019).
Practice development (PD), whilst not a panacea for all issues in healthcare, can be a feasible and effective solution to these two challenges. Contextual readiness of your healthcare setting can be assessed for translating evidence into your practice or to evaluate your workplace culture through analysing the factors that positively influence the quality triad. As the triad is underpinned by learning (Crowe and Manley 2019) and PD has a particular focus on active learning, you could use its tools to evaluate yourself, your service or your team through each of these lenses.
PD is focused on collaboration, inclusivity and a participative approach to developing person‐centred, safe and effective cultures (Manley et al. 2008). These principles were found to be lacking in international inquiries into maternity care. Therefore, PD is a useful method to facilitate improvement and transform care.
PD, with its focus on bottom‐up change, aims to align change ideas with people’s values and generate greater buy‐in, which in turn can lead to sustaining workplace transformation.
In this chapter we will describe the experience of transformation within maternity services, drawing from four different contributors in hospital settings across different countries. Transformational PD, person‐centred, safe and effective approaches were used to facilitate effective workplace cultures to flourish. An unexpected and positive consequence of the authors’ involvement was a turning point in their awareness of the effectiveness of this methodology. The critical recognition that PD could transcend boundaries of countries, health services, professional disciplines and positions was pivotal to the authors’ commitment to this methodology in the quest for improving maternity care.
Inclusivity, relatability, effectiveness – Ciaran’s Eureka
My experience of PD is relatively recent; however, the impact it has had on my practice as a consultant obstetrician has been enormous.
With an interest in multiprofessional learning, team training and human factors, the only context in which I had heard PD mentioned was in training and development. This was further confined to something that nurses and midwives do whilst medics do medical education.
A desire to provide the best care for women and families led me to understand that I needed to gain knowledge and skills in human factors, ergonomics and quality improvement. At the time I felt like a lone nut. A physician who preached that to prevent harm we needed to have more than excellent technical skills such as operating. I was promoting evidence that non‐technical skills were equally, if not more important in reducing the risk of harm ever occurring. Along the way I questioned two things which may resonate with many of you:
1 Why was implementing the research evidence into practice in some maternity units so challenging?
2 Why were some units outstanding, some poor and others eager to improve but just could not convert the successes of others into their local setting?
I sought formal training in clinical leadership and management, something that most of my peers and all my seniors declared was the fluffy stuff and I should stick to developing excellent technical skills. In a bid to help myself and them to identify with the benefits of my experiences, although different from theirs, I tried to demonstrate that both collectively aimed to improve outcomes. You will be familiar either as a clinical doctor yourself or as a non‐medic that doctors are an inquisitive, suspicious and highly competitive bunch. They require evidence that is robust and they are difficult to change unless the evidence is clear or there is an opportunity for professional development. Therefore, breaking boundaries and discussing measurement that did not mention a p‐value was challenging to say the least.
Although to this day there is no consensus definition of quality improvement, the ‘science’ of it made me as a medic identify with its merit. I was familiar with the struggles in language that colleagues had with translating human factors and ergonomics evidence from the nuclear and airline industries, so I was prepared for the same conversation converting the lessons from manufacturing to healthcare (Plsek 2014). The important thing for now was that I had something to put a name to, that was generating significant momentum in healthcare and to which I could speak a common technical language to convince medics of its benefits. This language was more familiar and defined by evidence; it was a language that did not frighten them and one which they could engage with.
I had experience through quality improvement (QI) projects of common and special cause variation generated by the systems within which humans live, experience and provide. I became increasingly interested in understanding more about this human element and how much it influenced sustained improvement.
Through human factors training I was acutely aware of how multiprofessional team training improved teamworking and clinical outcomes. I was keen to ensure that the training and development team in my workplace were united and that the staff identified the team by a common language. The midwives were called the PD team, whilst the obstetrician, me, was called the medical education lead. I suggested we needed an inclusive collective name and we agreed upon Faculty of Multiprofessional Learning in Maternity. The success of this strategy was not in the name but in the lived values of inclusivity, collaboration and engagement through the name (see PD principles Chapter 8).
I continued to explore the origins of PD and found myself identifying with it not on a training level but from an angle of improvement. Continuous learning within the workplace at a grassroots level building up small incremental changes refined through naturally occurring PD cycles without staff even knowing the term. I realised that the principles of PD, steeped in science, identified naturally with staff in a way that many had struggled to identify with the technical aspects of other improvement methods. My Eureka moment came as the worlds of human factors, safety science and improvement science came together.
This turning point led me to understand that PD was the key to unlocking why converting evidence into practice remains challenging and why some units have struggled to implement improvement. Without identifying with the inert values and beliefs of people, sustained change is challenging. This was just like my doctor colleagues who struggled to identify with my beliefs in human factors and improvement science all those years ago. Sound familiar?
I used PD tools to align the masses in a shared purpose, recognising that it is a method of continuous improvement that utilises the workplace as a continuous learning source. All improvement requires tremendous determination and all methods have their nuances. No one method is right in all circumstances. I believe in using the right skills and tools for the context within which they will work best. Sometimes measurement, statistical process control charts and hard QI measurement data speak well. However, I have found the greatest benefit of PD is its diversity in application and relatability to the values of women and frontline staff. A combination which if successful leads to sustained improvement and quality maternity services.
I have used PD to assess the cultural (safety, effectiveness, evaluative) context of a maternity setting: how ready is your service to implement change, best practice and research evidence? Without first understanding this readiness and addressing these contextual factors, implementing and sustaining transformational change is near on impossible. Once you have assessed your service contextual readiness you are in a position to use PD to co‐produce workplace transformation with staff. This requires facilitators who are familiar with PD methodology and tools (see Chapters 10 and 11 for more on facilitation).
Building contextual readiness – Cathy’s nemesis and enlightenment
It is understood that the principles, tools and methodological processes of PD can be implemented successfully in varied and diverse environments. However, it is essential that all approaches are contextually sensitive to place and person. What is described as an enabler in one setting may be seen very differently in another; what is