Content list

1. Executive summary......

2. The introduction and development of the PDF role......

3. The PDF role......

3.1 Key characteristics......

3.2 Variation: meeting Trusts’ needs......

3.3 Competency requirements, education and experience......

4. Accredited Work-Based Learning......

4.1 The EIHMS pilot module......

4.2 The pilot programmes......

4.3 Outcomes: learning, practice and patient care......

5. A sustainable framework: recommendations......

5.1 Trust support......

5.2 University support......

5.3 Practice development partnerships......

References......

Appendices are found on the CD-ROM included in this report:

APDFs’ Activity Reports

BEIHMS Handbook for AWBL pilot module: Using Work-based Learning to Enhance Practice, Level 2

CEIHMS Handbook for AWBL pilot module: Using Work-based Learning to Enhance Practice, Level 3

DAWBL pilot programme: Rehabilitation and PromotingIndependence for Older People, levels 2 and 3 (The East Surrey Primary Care Trust)

EAWBL pilot programme: Managing the Acutely Ill Patient on a Ward, levels 2 and 3 (The Royal Surrey County Hospital NHS Trust)

FAWBL pilot programme: E to F Grade Development Programme for Critical Care, level 3 (The Royal West Sussex Trust)

GMid-way Evaluation Questionnaire for Work Based Learning Programme

HEnd Evaluation Questionnaire for Work Based Learning Programme

IMentor Evaluation Questionnaire for Work Based Learning Programme

JManager/Assessor Evaluation Questionnaire for Work Based Learning Programme

KPilot AWBL programme evaluation

LEvaluation of non-accredited WBL programmes in mental health

MPaper on suicide prevention (The West Sussex Health and Social Care NHS Trust)

1. Executive summary

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This report describes the development of University accredited work-based learning (AWBL) programmes. This approach supports developing a more effective and responsive health service (DoH 2000a, 2000b) where patients’ needs are in focus (DoH 2002a, 2004c) and the workforce is supported to develop their skills and take on new roles (DoH 1999, 2002b, 2004a, 2004b). The AWBL approach provides a timely response to training requirements arising from the National Service Frameworks.

The approach reflects a partnership between NHS Trusts and a Higher Education Institution (HEI). Since January 2001 Practice Development Facilitator (PDF) roles were financed by the Surrey and Sussex Strategic Health Authority (SHA) and supported through an action research approach by the European Institute of Health and Medical Sciences (EIHMS) at the University of Surrey.

The PDF role is characterised by operating at many levels of service delivery, integrating Trust-wide strategic policies with clinical needs and concerns at ward level. The effectiveness of the role is dependent on the balancing of the critical outside perspective with practice knowledge in clinical teams. PDFs demonstrate flexibility and sensitivity to meet the particular needs of Trusts while taking on board the National Agenda. The success of the PDF role depends on the postholder’s professional and personal qualifications and available support structures.

PDFs have taken a variety of approaches to practice development and team learning. This report pays attention to the work to develop AWBL programmes supported by the EIHMS pilot module Using Work-based Learning to Enhance Practice, Levels 2 and 3. The report presents details of three pilot AWBL programmes:

  • Rehabilitation and Promoting Independence for Older People (details in Appendix D)
  • Managing the Acutely Ill Patient on a Ward (details in Appendix E)
  • E to F Grade Development Programme for Critical Care (details in Appendix F)

Findings from the evaluation demonstrate that the pilot AWBL programmes created a positive learning environment where staff demonstrated:

  • an increase in confidence regarding practical skills and academic writing;
  • increased knowledge base including ability and competency;
  • development of personal skills in leadership, communication and assertiveness;
  • the ability to relate theory to practice;
  • the confidence to converse with patients on issues of care that were previously difficult due to a lack of knowledge;
  • being a more effective member of the multi-professional team and sharing best practice;
  • more effective patient care and service delivery.

The successful implementation of AWBL programmes has potential to stimulate the learning environment in the workplace and improve staff’s job satisfaction as a result.

The report suggests recommendations for a sustainable framework for AWBL:

  • Trusts to provide support through the establishment of and sufficient support for PDF type roles.
  • HEI to provide support through the establishment of a flexible module framework, an AWBL co-ordinator role and area-specific lecturers to engage in AWBL projects and support research to ensure the evidence base.
  • Practice development partnerships involving Trusts, HEIs and patients/users.
  • Commitment from the SHA to fund and encourage practice development partnership initiatives.

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2. The introduction and development of the PDF role

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The Practice Development Facilitator (PDF) role was established in January 2001 in a joint initiative between the Surrey and Sussex Strategic Health Authority (SHA) and the European Institute of Health and Medical Sciences (EIHMS) at the University of Surrey.

The rationale behind the initiative was to support the development of innovative ways of delivering continuing professional development (CPD) in the practice setting (DoH 1999, 2004b). This is in line with the modernisation framework as set out by the Department of Health in the documents The NHS Plan (DoH 2000a) and Liberating the Talents (DoH 2000b). The project aimed to bridge the theory-practice gap, to strengthen the evidence base for healthcare practice (DoH 2000b) and to improve patient outcomes by shifting the balance of power (DoH 2002a) and putting people at the heart of the service, as outlined in the NHS Improvement Plan (2004c).

National Service Frameworks were key drivers for the establishment of PDF roles in mental health, critical care and intermediate/primary care. The Trusts involved were:

  • Ashford and St Peter’s Hospitals NHS Trust
  • East Surrey PCT
  • FrimleyParkHospital NHS Trust
  • North West Surrey Mental Health Partnership NHS Trust
  • RoyalSurreyCountyHospital NHS Trust
  • Royal West Sussex NHS Trust
  • Surrey Hampshire Borders NHS Trust
  • Surrey Heath and Woking PCT
  • Surrey Oaklands NHS Trust
  • Surrey & Sussex NHS Trust
  • West Sussex Health and Social Care NHS Trust

Figure 2.1 overleaf illustrates the Trusts’ involvement throughout the period January 2001 to December 2004. By detailing the months of PDFs’ employment the figure also demonstrates issues of continuity and retention in the PDF roles.

The University of Surrey was funded by the Surrey and Sussex SHA to engage with the PDFs in an action research approach. This engagement involved three phases.

Action research is a participatory approach to develop a product or achieve an outcome by using research in a circular feedback process (Bate 2000).

Phase One

In the first phase (January 2001 – December 2002), this engagement paid attention to the introduction and development of the PDF role. The purpose was to put in place a system of support for the PDFs to meet service expectations of the post. Three approaches were taken. Firstly, supervision groups with a senior member of the University (mental health and critical care with intermediate care) to address the individual development needs of the PDFs. Secondly, the Head of Academic and Practice Development negotiated with the PDFs to set up a project monitoring and evaluation group consisting of PDFs, their managers and the University (this group evolved to become the project’s steering group). Finally, an external facilitator was brought in to support and develop the PDFs’ knowledge, understanding and skills of critical reflection to manage and evaluate the post. The development programme for the PDFs in the period 2001-2003 was subsequently formulated into a module ‘Enabling Innovative Practice’, 20 credits at level 3 and offered within the EIHMS Lifelong Learning framework.

Phase Two

As SHA funding was provided for continuing the PDF roles for a further two years, focus was directed towards the development and piloting of a framework for University quality assuring and accreditation of work-based learning supporting practice development in Trusts. The University of Surrey was funded (July 2003 – December 2004) to reengage with an action research approach to support this development and evaluation work.

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Figure 2.1: Overview of Trusts’ and PDFs’ involvement in the project period 2001 – 2004, Phases One and Two

Clinical Area / Trust / 2001 / 2002 / 2003 / 2004
Critical Care / Ashford and St Peter Hospitals NHS Trust / Karen Coertze
Ruth Towell / K. Tylor / Bates
FrimleyParkHospital NHS Trust / Alison Stevens / Sam Keating (leave 6/03-11/03) / S. Keating p/t
RoyalSurreyCountyHospital NHS Trust / Catherine Derham / Rosemary Maundrill
Royal West Sussex NHS Trust / Jo Morgan (has continued Trust funded PDF role in Intensive Care)
Surrey and Sussex NHS Trust / Paula Sloan
Intermediate/ Primary Care / East Surrey PCT / Liz Mouland (has continued PDF work as Nurse Consultant)
Surrey Heath and Woking PCT / Sandra Evans / Kirsty Thurlby (leave 10/03-6/04)
Mental Health / North West Surrey Mental Health Partnership NHS Trust / Kevin Acott (left to Surrey Oaklands) / Eileen Welland
Surrey Hampshire Borders NHS Trust / Camille Whiby
Surrey Oaklands NHS Trust / Sara Opie / Kevin Acott
West Sussex Health and Social Care NHS Trust / Bob Birtwell
Alex Jones

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PDFs were given Honorary Contracts with the University of Surrey and provided 0.2 fte of their time for this collaboration.

Meetings between PDFs and the EIHMS team were held at a regular interval. Between July 2003 and December 2004 a total of 29 PDF meetings were held at the University Campus. At these meetings PDFs presented and discussed their ongoing work with each other and worked collaboratively with University staff to develop a collective approach to service development through the provision of accredited work-based learning (see also section 4). Summaries of the PDF meetings were distributed by email shortly after each meeting to keep an audit trail of the projects’ development and to allow PDFs who couldn’t attend the meeting to keep informed on the progress.

At the regular PDF meetings the EIHMS team comprised Ms. Alison Rhodes (Tutor with expertise in development and work-based learning and member of the workgroup for ‘Negotiated Learning’ at EIHMS) and Dr John Aggergaard Larsen (Research Fellow with a Social Sciences background and expertise in qualitative and participatory research methods). The wider EIHMS team comprised the PDF Strategic Group with the additional members: Dr Margaret Volante (Head of Practice Learning and Education in EIHMS), Professor Pam Smith (Director of the Centre for Research in Nursing and Midwifery Education and an experienced action researcher), Dr Pat Colliety (Senior Tutor, has conducted a study on practice development and is supporting the community PDFs in Phase Three – see below) and Ms. Sue Ryle (Head of Continuing Professional Development and Postgraduate Programmes at EIHMS). Additional support for the development of Level 1 AWBL programmes was provided by Ms. Melaine Coward (Deputy to Ms. Ryle and responsible for co-ordinating the CPD framework at EIHMS). During 2004 the EIHMS PDF Strategic Group met monthly to discuss the progression of the PDF project and how it might relate to the education provision strategy for EIHMS.

A PDF Steering Group was established to provide monitoring and evaluation (see Phase One) through regular, half-yearly meetings involving PDFs, PDFs’ line managers, the EIHMS team and, since September 2002, headed by Ms. Sheila McKinley from the Surrey and Sussex SHA. Since the end of 2003 the first hour of the PDF Steering Group meetings did not include the PDFs. The meetings set out the strategic aims for the development of the PDF project and defined objectives for PDFs and the EIHMS team to deliver. An additional component of the PDF Steering Group meetings was to present an update on the project’s progress and to allow PDFs to express their experiences and views. The meetings have been essential to keep the stakeholders updated on the progress and agree a direction for the project’s development.

Since 2003 Dr Charlotte Ramage and Ms. Helen Stanley from the University of Brighton have attended PDF Steering Group meetings to contribute their experience with setting up Negotiated Work Based Learning. In addition, separate meetings have been held with the University of Brighton to inform the work in the PDF project.

Phase Three

A third phase of the project started in January 2004 as the Surrey and Sussex SHA provided two years funding for PDFs in primary care. EIHMS is supporting these community PDFs in a parallel project (key responsible person is Dr Pat Colliety). This phase involves these Trusts:

  • Adur, Arun and Worthing PCT
  • Eastbourne Downs PCT
  • Horsham and Chanctonbury PCT and Crawley PCT
  • North Surrey PCT
  • Surrey Heath and Woking PCT

Key points

PDFs have been introduced in Surrey and Sussex through three phases:

  • Phase One (January 2001 – December 2002): PDF roles were introduced and they worked on Trust specific practice development needs.
  • Phase Two (January 2003 – December 2004): focus was directed towards developing AWBL programmes and suggest a sustainable framework for future Trust-HEI partnership.
  • Phase Three (January 2004 – December 2006): PDFs have been introduced in primary care and will build on previous experiences.

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3. The PDF role

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The PDF role presents a unique mix of clinical, strategic, interpersonal and educational functions, which distinguishes it from other practice educational roles (see e.g. Ramage 2004). The PDF role pays special attention to the development of an organisational culture that genuinely supports innovative and creative clinical practice, and the learning – and integration – of new skills. This section specifies the characteristics to avoid the lack of clarity and confusion which often accompanies the introduction of new clinical roles and titles (Jones n.d.).

3.1 Key characteristics

Key characteristics of the PDF role became apparent at the PDF meetings (see section 2). The discussions continued during collaborative writing for academic publication (Larsen et al., n.d.) which further stimulated the ongoing reflexive process.

Getting into practice

It is crucial that the PDF is actively involved in clinical work in the Trust. Working alongside clinical colleagues gives the PDF insight into the work culture at ward level and complexities related to the clinical work as well as staff-collaboration. At times PDFs have been struggling to establish a recognisable ‘membership role’ as an insider in the practice setting. Some PDFs have reported initially being seen as ‘a spy’ sent by management. PDFs have also felt tensions with other senior clinical staff who at times felt threatened by the PDF, challenging their position and authority in the staff hierarchy. PDFs have generally experienced that it took time, patience and continued effort to be seen as having ‘clinical credibility’ and recognised as having a positive and supportive function among staff. Practice development parallels good patient care: true and honest engagement is a necessary and respectful first stage. This forms a basis for the development of trust, which is essential for staff to engage in learning and practice change.

Working at a strategic level

While working alongside clinical colleagues the PDF has also an important strategic function, stimulating best practice and working towards the Trust’s performance targets. The PDF has to be ‘politically aware’ of these strategic requirements and seek to implement them in practice, while bridging the gap between policy formulations and the requirements of everyday practice. PDFs have benefited from taking an active part in Trust-wide strategic meetings concerning training provision and practice development (e.g. ‘Training and Implementation Group’ or ‘Practice Development Group’) as well as the relevant clinical group (e.g. ‘Nursing Forum’ or ‘Nursing and Midwifery Group’). The Trust-wide strategic involvement gives the PDF insight into ‘the bigger picture’ and allows identification of structural issues to direct their work focus and avoid ‘working in a silo’. Equally, by being a member of these groupings the PDF has a direct voice at a Trust level and is better able to make a significant impact on Trust practice development priorities.

‘Drip-drip-drip’ approach

Due to the above mentioned characteristics of the work PDFs have to be ‘thick skinned’ and not expect quick and immediate changes to practice development. They are by the very nature of the role in it for ‘the long haul’ if they are to succeed. Practice development is an ongoing process which demands continuous attention and deliberate action. It has to do with creating and sustaining a certain practice culture which embodies the ideology and practice of a ‘learning environment’. The PDF is, as the title says, the facilitator of this ideology and practice. PDFs have described how they see themselves as providing their clinical colleagues and the practice culture with the ‘optimism’ and ‘energy’ to develop and sustain best practice.

Insider-outsider status

The PDF role incorporates insider and outsider characteristics in terms of the clinical practice environment. PDFs are working hard to be recognised as insiders in order to have clinical credibility and be seen by clinical staff as a positive resource for their work. At the same time PDFs are critically evaluating practice in order to stimulate the development and sustainability of best practice. PDFs have reported that they have to be assertive and demonstrate positive energy and optimism to achieve this. The social position and interpersonal demands can be emotionally draining for the PDF, and especially in the beginning it may be necessary to have ‘thick skin’. It is, however, an important function of the role to be in that insider-outsider position as it is necessary in order to identify problems and suggest changes.