Kim Manley, Angie Titchen and Sally Hardy
Introduction Throughout this book, we aim to provide a broad, interwoven vision of what is possible in nursing practice. This introductory chapter places nursing practice expertise within a clinical career framework that encompasses five interdependent domains. The first domain is about achieving professional expertise and artistry in the nursepatient relationship. The other four domains are about developing expertise in implementing and sustaining person-centred systems. The development of person-centred systems requires expertise that includes the facilitation of individuals, teams, systems, learning, research, inquiry, evaluation and change in practice, so as to enable a culture of effectiveness to develop in the workplace. Other chapters of this book provide more detailed examples that illustrate expertise across some or all of the domains outlined in this chapter.
This chapter will focus on the following:
1. The domain of nursing practice expertise within the nurse-patient relationship.
2. The four domains associated with developing person-centred systems, namely,
(i) facilitating practice change and a culture of effectiveness in the workplace through leadership;
(ii) facilitating inquiry, evaluation and evidence use in practice;
(iii) facilitating learning and a work-based learning culture, where learning in and from practice is the norm and all learning feeds into practice transformation;
(iv) using consultancy approaches that foster self-sufficiency in problem-solving across teams and organisations.
3. Identifying the relationships between various roles that encompass expertise in nursing practice and person-centred systems. For example advanced, specialist and consultant nurse practice and other clinically related career opportunities beyond the consultant nurse role.
The context of nursing practice expertise
Inherent in all nursing practice career frameworks is a spectrum of expertise that spans the range of domains above. This spectrum is necessary for practice teams and cultures to be experienced as person centred and evidence based. The establishment of person-centred systems enables patients and users to receive person-centred and evidence-based care, regardless of whether the most immediate provider of care has expertise or not. The reason for this is that such systems create cultures that enable a consistently high quality of nursing to be experienced by patients and users from the whole team. In other words, this spectrum or span of expertise is underpinned by an assumption that nursing is about both the relationship with the person who has health or illness needs, and also, the context in which nursing takes place (Manley, 2000) (Box 1.1).
The context for nursing practice therefore extends from that most immediate to the nurse-patient relationship, through to the health care team and onto the patient's journey, which may cross a number of interfaces. It is at these interfaces that nursing practice expertise has most potential for developing person-centred systems (McCormack et al., 2008a, 2008b). This is not to deny that nursing does and should not have influence at other levels, such as the organisational level - it does (Aiken et al., 2002; McCormack et al., 2008b), or that other levels of organisation aren't important - they are (McCormack et al., 1999) but the predominant focus here is on the workplace rather than the organisation.
Expertise: a lifetime's journey
Although there is an interdependence in the development of expertise across the five domains, it is recognised that individuals follow different career trajectories and that these are not necessarily linear. By focusing on the different domains that constitute the spectrum of nursing expertise from that located within the individual nurse-patient relationship through to that related to implementing and sustaining person-centred systems, it is hoped that different starting points and professional experiences are recognised and greater fluidity in career progression is valued. Expertise doesn't develop overnight. It happens through using workplace experiences as the main resource for learning and inquiry. These experiences are combined with an impetus and desire for refining everyday practice, through structured and supported reflection that has potential to transform practice, the individual and the team, within an everyday culture that supports this transformation (Manley, 2004). This is a lifetime's journey within the context of lifelong learning, one that requires us working with others and exposing our practice to critique. Working with and exposure to critique were characteristics of the Royal College of Nursing's (RCN's) Expertise In Practice Project (EPP; Manley & Garbett, 2000; Hardy et al., 2002; Manley et al., 2005; Hardy et al., 2006, 2007) in which participants, who were recognised by their colleagues as having expertise, were involved in trying to understand and articulate their nursing expertise and its outcomes. Through the process of portfolio development and with the help of a critical companion (Titchen, 2004), participants, by the end of the research, could explain not only why they had expertise, but also what the outcome of this expertise was on patients, colleagues and the service. This study led to the recognition that even experts needed help with unpicking and articulating their expertise, as well as the processes for developing it further in themselves and others. A set of standards emerged that would assist others in their development of not just clinical expertise but also person-centred systems (RCN, 2004a, 2004b). The four domains associated with developing these systems will be described later once the domain of person-centred expertise has been considered in more depth.
Nursing practice: person-centred expertise
Expertise in person-centred practice
The contemporary understanding of nursing expertise presented here (Box 1.2; Figure 1.1) is based on the findings of the RCN's EPP (Manley & Garbett, 2000; Hardy et al., 2002; Manley et al., 2005; Hardy et al., 2006, 2007) and can be clearly traced to the original research of Benner (1984), Benner and Wrubel (1989) and Benner et al. (1996). Chapter 3 discusses these and other early works and sets out the literature landscape concerned with expertise in nursing and its development. This chapter focuses on the EPP which spanned a period from May 1998 and continued through to 2004. It included six cohorts of practising nurses working in four countries of England, Wales, Scotland and Northern Ireland. The project aimed to develop a deep and rich understanding of nursing practice expertise across diverse clinical specialities, through the identification and verification of its attributes and enabling factors. Derived from insights and augmented by a comprehensive analysis of the literature, these attributes and enabling factors formed the conceptual framework for the project (Manley & McCormack, 1997).
Benner and her colleagues used phenomenology to interpret and illustrate nursing expertise through a number of paradigm cases and exemplars that showed overarching and specific aspects of expertise, respectively. In contrast, the EPP drew on emancipatory action research (Grundy, 1982) and fourth generation evaluation (Guba & Lincoln, 1989). The latter is an approach to social research that integrates action in the workplace with the concerns, claims and issues of stakeholders. Schratz and Walker (1995) suggest that social research is about enabling practitioners to become more critical about their practice through identifying and evaluating their actions and decisions. Whilst supporting this notion, the EPP went way beyond it by inviting practitioners to become practitioner researchers who, simultaneously, investigated and developed their own expertise. To help participants to develop the necessary skill sets for practitioner research, participants and their critical companions were invited to join monthly action learning sets facilitated by two members of the research team. Participants also met regularly with their chosen critical companion (Titchen, 2001) in the workplace, in addition to collaboratively gathering evidence of and about the nurse participants' practice. The methodology of this study is further described in Chapter 3.
The outcomes of this project included a framework of expertise that offers a language for nurses to articulate and share with others what constitutes their practice expertise, thus providing a greater level of insight and articulation of what occurs between the expert practitioner and the people they care for. Table 1.1 sets out refinements and additions to the attributes identified in the original concept analysis conducted by Manley and McCormack (1997). Refinements and additions were established through an overall analysis of the nurse participants' portfolios of evidence and review of literature since 1997.
Analysis of the portfolios in the EPP also supported the three enabling factors of expertise identified in the original concept analysis, that is, reflective ability (reflexivity), organisation of practice (capacity to critically control all of their interactions to impact on the organisation through being able to see the bigger picture) and autonomy and authority (capacity for making decisions, taking responsibility for any arising consequences and willingness to challenge whole teams and senior colleagues if patient care was compromised). In addition, the EPP demonstrated that nurses with expertise effect change and facilitate both performance and organisational development.
Apart from Titchen's (2000, 2001) study, the processes of encouraging and supporting practitioners to deconstruct and then reconstruct their practice have not occurred before in an investigation of practice expertise. Indeed, the conclusion of other research undertaken to date (e.g. from our search of the literature related to practice expertise between 1996 and 2008) is that supporting nurses with expertise as practitioner researchers is puzzling and problematic. This study, therefore, makes another contribution in relation to setting out the practical know-how of enabling practitioner research. Thereby, it offers a unique framework for helping practitioners to inquire, critique and, perhaps most importantly, continue to learn from the process of investigating their practice, ongoing development and the articulation of their practice expertise as illustrated by participants in the EPP (e.g. Richmond, 2003; Titchen & McGinley, 2003; Brown & Scott, 2004; McCormack & Henderson, 2007).
Originally presented as a typology (as in Table 1.1), we concluded that the dynamic relationships between the attributes were not articulated and how nurses use them in a holistic way within their practice were not shown. So building on Titchen's (2001) and Titchen and McGinley's (2003) findings, we re-presented the typology as shown in Figure 1.1 and introduced professional artistry as the overarching enabling factor into our framework. Professional artistry enables the blending and melding of the attributes into unique configurations for each unique patient and context. The dimensions of professional artistry include, for example, different kinds of knowledge, ways of knowing, multiple intelligences, creative imagination and therapeutic use of self. These dimensions and the processes of professional artistry are described in Chapters 3 and 12. Whilst further research is required, we propose that professional artistry includes the reflexive and metacognitive p rocesses that underlie the three enabling factors above.
Although the EPP primarily focused on what happened within the nurse patient relationship, it was also evident that expert nurses impacted on their colleagues and the organisations in which they were located. This illustrates how expertise in nursing spans and is interdependent with expertise in the other domains necessary for developing person-centred systems. As nurses progress through the clinical career ladder, they develop expertise that extends beyond the world of the nursepatient relationship to the immediate systems in which care provision is located.
Expertise in developing person-centred systems
Kitwood defines person-centredness as
a standing or status that is bestowed upon one human being, by others, in the context of relationship and social being. It implies recognition, respect and trust. Kitwood, 1997, p. 8
Person-centred systems are characterised in the workplace, regardless of setting, by the presence of structures, processes and patterns of behaviour that are embedded in the principles of person-centred care and are manifested in a culture that is person-centred (McCormack et al., 2008b). These principles include maximising opportunities for enabling continuity and integration of services by keeping the person at the centre of decision-making, minimising discontinuity through systems re-design, helping individuals and teams to work effectively, and the building of social capital (McCormack et al., 2008b).
Social capital refers to the connections between individuals and is located in the relationships and social networks identified by the norms of reciprocity and trustworthiness that arise from these connections (Putnam, 1993; Adler & Kwon, 2002). Just like economic capital, social capital can be accumulated for distribution among society based on the idea that the more connected a citizen is to his or her social networks, the more social capital or resource that is available for citizens to draw upon in order to improve their lives. The extent to which social capital exists in a given context critically influences the success of collective and collaborative work (Putnam, 1993). Social capital leads to greater potential for networking and commitment to cooperative action (Cohen & Prusak, 2001) and therefore contributes to creating workplace cultures where people flourish through trust, shared values, mutual understanding and respect. Manley (2000, 2004) and Manley et al. (2007) describe the culture arising from such principles as an effective workplace culture, one that is associated with specific attributes that include the values, patterns of behaviours, structures and processes necessary for achieving social capital, person-centredness, evidence-based care, and individual and team effectiveness.
Person-centred systems through their structures and processes therefore actively support practitioners and practice teams to deliver on key values. This characteristic is demonstrated well by the Magnet Hospital Programme and the outcomes it achieves (Aiken et al., 2002). In Magnet Hospitals, nursing is highly valued and supported and this is reflected in the quality of care experienced by patients. Enabling person-centred systems to develop in practice requires a specific skill set that builds on nursing practice expertise located in the nurse-patient relationship. This skill set is outlined in Box 1.3, but for greatest effect, needs to be located as near to the interface of care between health care providers and recipients as possible (Manley & Webster, 2006).
These skills were derived from a set of methods, for example, agreeing ethical processes, analysing stakeholder roles and ways of engaging stakeholders, being person centred, clarifying the development focus, collaborative working relationship, continuous reflective learning, and developing a shared vision, among others known to be influential in developing practice (McCormack et al., 2006). This skill set underpins the following four domains necessary for developing person-centred systems:
facilitating learning and a work-based learning culture;
facilitating inquiry, evaluation and evidence use in practice;
facilitating a culture of effectiveness through leadership;
using consultancy approaches that foster self-sufficiency in problem-solving across teams and organisations.
The four domains build on the first - nursing practice expertise in the nurse patient relationship - that captures the scope of the clinical career framework in nursing. Developing expertise in the four domains is now considered from the perspectives and the frameworks that currently exist to describe them.
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Excerpted from Revealing Nursing Expertise Through Practitioner Inquiry by Sally Hardy Angie Titchen Brendan McCormack Kim Manley Copyright © 2009 by John Wiley & Sons, Ltd. Excerpted by permission.
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