Plotting care: A modelling technique for visioning nursing practice in current and future contexts

Cheryle Moss
Associate Professor Nursing, Research and Practice Development, School of Nursing and Midwifery, Faculty of Medicine, Nursing and Health Sciences, Monash University, Clayton VIC, Australia

Ken Walsh
Professor of Nursing Practice Development, School of Nursing, Midwifery and Indigenous Health, University of Wollongong, and South East Sydney and Illawarra Area Health Service, Wollongong NSW. Australia

Jacquie Mitchell
Service Manager, Thames Hospital & Community, Waikato District Health Board, New Zealand

PP: 188 - 201

Abstract

Health professionals in health-care organisations are frequently challenged to strategise their services, reshape patterns of care delivery and to adapt to changing environments. Relocation of services into new hospital buildings is one example of a situation that generates these challenges. In this paper the authors discuss an innovative modelling strategy that was employed to assist nurses to explore their current daily care practices, to visualise them in the context of proposed new buildings, and to work towards planning care in readiness for the new context. The modelling technique of ‘plotting' is presented as a way of capturing the natural spatial-service wisdom that exist within teams, and assisting them to translate their knowledge of this to each other and to co-operatively work towards a new clinical future. Plotting will be of use to health professionals, clinical leaders and educators who are interested in spatial analysis of care and other health service practices.

Keywords

Modelling, plotting, organisational change, new hospital buildings, practice development, nursing

Article Text

The stimulus for the development and use of plotting care as a modelling technique was a clinical context where a health care organisation was planning significant service and physical re-development of the inpatient units and the ambulatory service areas.  Confronted with the scale and relative rapidity of planned change, staff needed to find effective ways to support each other, to imagine their work in new buildings and contexts of care, and to generate transitions in practice that would move development of their services towards the new context.

It is argued that plotting is a helpful technique that can be used by clinical groups to visualise, through modelling, space-practice-work relationships.  The use of spatial modelling can assist teams to re-configure their practices and workflow in their units and between units, or as a means of planning for care in new settings or groupings of patients and staff. To illustrate the usefulness and practicalities involved with the technique of plotting a practical case-study is presented.

Theoretical background

Plotting traditionally has been used to create a visual display of the location(s) of an object or groups of objects in relation to each other, and to capture movements at particular points of time.  These visual processes and displays can be used for navigation, capturing movement, or for exploring the relationships of space and objects.  Plotting can be used as a means for displaying information, for product visualisation, to enhance learning, to improve knowledge transfer, and to create simulations (Burkhard & Meier, 2004; Hansen & Johnson, 2004).

To develop the plotting care approach we drew three key conceptual aspects together.  The first of these, practice development (McCormack, Manley & Garbett 2004; Manley, McCormack & Wilson 2008), particularly the principles of collaborative engagement (Walsh, Moss, Lawless & Allbon 2005) and action learning (Dewing 2008; McGill & Brockbank 2004), was used to frame the overall process. The recognition that visual modelling (Burkhardt 2004; Burkhardt & Meier 2005; Hansen & Johnson, 2004) can be united with the principles of action and experiential learning (Billet 2004; Dewing 2008; Kolb, 1984; Laschinger 1990) was used to shape the medium of plotting into a practical technique and became the second conceptual aspect.  In the third conceptual aspect, we drew in recognition of the degree and process of change with which the organisation and the clinical teams were grappling and we linked this to literature about working in context (eg. site specific practice, workplace knowledge and culture) (Easterby-Smith & Antonacopoulou 2006; Edvarsson & Street 2007; Eraut 2004) and about organisational learning (Senge 2006; Ward & McCormack 2000; Wenger 1999).

A brief exploration of the literature (using CINAHL, and MEDLINE data bases) revealed no evidence that the application of modelling techniques such as plotting, had been used with clinical teams to assist them through the processes of negotiating changes in units related to new buildings, or shifts in the systems of care delivery. We also found that little work had been conducted concerning the physical context in which teams work and how changes to this context might impact on team functioning and the organisation of patient care and the management of work effort. 

What is known is that the physical environment of an organisation can impact on its culture and how it functions (Cameron & Quinn 2005).  Clinical nursing practice does not occur in a vacuum, but it involves individuals, situational contexts and practice cultures (Street 1992; Street 1995).  All of these contribute to the construction and management of work. In the construction and performance of everyday practice, people both shape and are shaped by the culture of work (Moss & Chittenden 2008; Street 1992; Street 1995). Ease of work and working is achieved by habitual knowing - knowing of the routines, procedures, how fast to walk, the location of objects and tools, use space and motion (Ford & Walsh 1994; Strange 2001; Walsh & Ford, 1990). Drawing on this knowledge it is easy to see why when we change a routine, a procedure, the location of an office or a tool, or shift the design of an area everyday practice and patient care becomes disrupted. Also that clinicians, such as nurses, working the space need to respond to the new situations and to develop adjusted processes in practice.

In relation to planning for the provision of care, or workplace activities in new buildings or in new contexts, there needs to be acknowledgement that employees have a deep understanding of the organisational system in which they work, and that because of this they are well placed to inform workplace design (Lyles & Easterby-Smith 2003; McCormack et al 2004; O'May & Buchan 1999; Wenger, McDermott & Snyder 2002).  Bierema (2000) argues that, for those concerned with organisational change, there is a need to understand the influence of cultural knowledge within the organisation itself and how it is constructed, monitored and used by different organisational sub-cultures.

Change agents report the importance of generating a sense of vision and agreement on the overall goal of change in creating successful change (McCormack et al 2004; McCormack Manley & Walsh 2008; Manley et al 2008).  Studies also report the importance of gaining strong participation in the change processes and of using a whole systems approach, mapping, analysis and redesign and translating evidence into practice (Clarke et al 2004; Harvey et al 2002; McDonald & Viehbeck 2007; Rycroft-Malone et al 2002). We believe that modelling which utilises blends of visualisation, imitation of spatial contexts, and representation of teams delivering patient care can also support these transitions.

Often when change plans are developed, not enough attention is paid to understanding the local context and local practice and the way it works (Clarke et al 2004; Rycroft-Malone et al 2002). This includes exploring what aspects of current practice should remain and which should evolve or change and the mechanisms that can assist those involved make the necessary transitions and translations needed to achieve the change. Nursing practice is complex and local contexts of care add to this complexity.

The literature on sustaining and building learning cultures within teams and organisations proved helpful in assisting thinking about the importance of local knowledge and team involvement in planning for change.  This included Senge's (2006) work on genuinely using local capacities; Schulz's (2005) work on developing learning and actions from local theories of practice; and Wilson's (2005) work on developing a vision for teamwork.  Community of practice theories (Andrew, Tolson & Ferguson 2007; Wenger 1999; Wenger et al 2002) including workplace participatory practices (Billett 2004; Billett & Sommerville 2004; Moore 2004) and on the importance of stimulating voice and freedoms to engage (Aranda 2001; Binnie & Titchen 1999; Fenwick 2003) were important in generating ideas about how to achieve participation, and to build on the knowledge of the local clinical teams.

Further literature on the moral and ethical conditions necessary to support workplace development (Lawless & Moss 2007; Rodney et al 2006; Varcoe et al 2004; Wilson 2005) provided guidance on group values and importance of workplace integrity in any group activity.  Rodney's (1997) PhD thesis on the development of connectedness and trust as nurses' enact their moral agency within the organisational context, and her (Rodney) paper with Starzomski (1993) on 'Constraints on the moral agency of nurses' were particularly useful.

New building programs, such as the one cited in this paper often bring with them concomitant pressures for reformation, work redesign, and re-development of care pathways.  Our personal experience with the timelines for the development of new buildings reveals that they are often very tight and associated pressures for efficient decision-making can compel managers and planners to focus primarily on global strategising and big picture thinking in relation to planned change. These pressures can draw attention away from local practices of teams within the workplace and may lead to underdevelopment of much needed cultural engagement and reformation in the processes of change. It is important to pay attention to local change, to work with what is, to find ways that support transition and translation and to evolve practical strategies to commence the evolution needed.

Building on all this information and the theories behind the ideas, we developed a plotting modelling technique and planned a workshop for staff in which the technique could be used.  We were aware of the importance of developing local nursing team engagement, understanding and articulation of current and local practices in the delivery of care, and of using group practice experience and wisdom in the visualisation of potentially different practices and new patient care pathways in the new buildings. In the next sections of the paper we offer a descriptive account of the workshop and how the plotting modelling technique was used within it.

Workshop aims and objectives

... continues ...

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