Knowledge for Practice, Management and Development in social work

 

Knowledge for practice, management and development Malcolm Payne, Director, Psycho-social and Spiritual Care, St Christopher’s Hospice, London.

 Social work knowledges and good practice

Social work, like many professions, is both a practice and a set of knowledges. That is, people who form an occupational group that is seen as a profession, and people who interact with members of the group, primarily see the occupation as about doing something in the world. What they do is i s significantly affected by how the they y understand the world – by their knowledge of it. Their skill in practice is developed by incorporating those knowledges into actions that form practice. The occupation is constructed by the practices; people look at what the professionals are doing and can decide whether or not what is being done is that profession or not. Behind the practice, however, the members of the profession use those knowledges as the basis for managing and developing their work. Management is about controlling the practice so that it meets the needs that it is intended to meet to the standards that the people whom the profession serves require. r equire. Development is about strengthening the practice. Practice, management and development are therefore entwined together,  but they are different aspects of professional practice. Management and development work is often done separately from professional practice and is part of the managerial function of the agencies in which practice takes place. They may, therefore, be experienced as separate activities from practice, the three activities interacting or  contributing to each other, but being separated in an agency because they are done by different people or as part of separate organisational structures. When we look at most social work services, many of the aspects that give them their  highest quality are about the characteristics of the interpersonal relationships between staff and the users of the service. By developing staff skills and ma maintaining intaining good morale within the agency agenc y, we can develop and support this kind of quality, but very often the skills and knowledge that create the right atmosphere and standards are hard to assess, to describe and to encourage. For example, a disabled user who was close to death went on a seaside visit; a member of staff noticed that she was staring at the water, and discovered that she had been born near the sea, and wanted to paddle in the water again, for one last time. It was difficult, but it proved possible to arrange this. While we can organise and train staff to be flexible when they are asked for  something of this kind, it is hard to train staff to ‘notice’ someone’s someone’s preoccupations. However, the ‘skill of noticing’ is not wholly a personal trait. It is a behaviour that is learned. We We can reinforce rei nforce it when individuals show it, we can point it out to others as a useful behaviour when it occurs, we can support it by responding positively to suggestions when it arises. If a team leader had not said ‘Great, we’ll organise to get her into the water,’ to the member of staff who noticed, she would be less likely to notice something in the future. One of the important aspects of a successful caring organisation, therefore, is identifying what happens when ‘good practice’ occurs, managing the organisation in such a way that this is recorded and built into knowledge in such a way that it can be

 

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widely used. This can only be a collective endeavour, since to reinforce good practice consistently requires everybody in the organisation to reach agreement about what good practice is, so that ‘mixed messages’ are not conveyed, by some staff who do not want to be inconvenienced by flexible responses, for example. Another factor is the management of recording. Records are always written to respond to the needs of their  audience, not necessarily to present an ‘accurate’ account of an event (Askeland and Payne, 1999). For example, if records are used to check on performance, staff will record things that are approved by the management, rather than reflecting their own  judgements about what is important (Garfinkel, 1967). Processes also have to exist in the organisation to convert piecemeal understandings within an organisation into structured knowledge that can then be tested by more formal means. What is needed therefore, is a process of organisational reflection. Individual reflection is a widely acknowledged process in professions that work with all the variability of human beings. Instead of ‘technical rationality’ in which evidence is accumulated through formal research and knowledge-building processes, Schön (1983) argues that professions such as social work, teaching teac hing and nursing undertake a  process of ‘practical experimentation’ as they practise. From this process, they develop additional guidelines for practice. The problem with this formulation is that there is no way in which individual practical experiments can be developed into formal knowledge (Payne, 2002). A process of organisational reflection is one way in which this can be achieved. To build knowledges in a social work organisation, therefore, structures of  organisational learning and reflection need to build practice understanding into knowledges that can be used in management and development. This enables them to  be generalised more widely in the organisation and then beyond it as a contribution to  professional knowledges. But how is it possible to do this in a working organisation? One requirement is to believe that knowledges emerge from continuing practice and that organisations need to be managed to do so. Currently, the assumption of much knowledge development activity is that it is separate from practice activity, and that the separation is required in order to give rigour and unbiased independence to evidence that contributes to practice, management and development. For example, research is seen as undertaken primarily in universities primarily by scholars, and development is seen as primarily undertaken by managers in development departments of agencies. To try to incorporate these activities into everyday practice is seen by many managers as deviation from the main purpose of the service, by  practitioners as presenting them with impossible conflicts in priority and by academics as risking bias and priority to ‘spin’ on behalf of the organisation or   practitioners instead of independent observation and a nd knowledge development. However, the qualitative argument is that knowledges for management and development will be more effective if developed from practice. Debate about the interaction between theory and practice has resolved itself to the point where a variety of potential interactions are assumed to be possible. This paper argues that such interactions have to be actively sought and developed of they are to be successful in organisations.

 

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Related to this, present-day social work is often carried out in multiprofessional settings or in agencies where the social work is a ‘secondary’ profess profession; ion; that is, the ethos and work of the agency is dominated by other perspectives and knowledges. This is true of health care, education and criminal justice organisations where social work is a contributor but not the main profession involved. Case study: St Christopher’s Hospice

The following account of knowledge management at St Christopher’s Hospice, a  palliative care service in south London, provides a case study of how some of the knowledge management issues for social work within a multiprofessional service may  be dealt with. I have chosen to present a case study in order to describe the variety of   possible routes by which knowledge might emerge from practice, prac tice, and also to provide a model of generalising from practice to knowledge and development. After an initial description of the organisation and its work, to place the discussion of knowledge management in context, the case study examines how knowledge emerges from formal research, user and carer involvement and clinical governance processes. St Christopher’s Hospice is a palliative care service for people who are dying,  providing medical and nursing care with 48 beds to alleviate symptoms and manage the disabilities and illnesses of life-limiting illness. It also provides nursing care and medical consultation at home for about 500 patients at any one time. Like much social  provision, it is multiprofessional, to integrate a range of professions and services. These include a day care service, with artists and physical care, complementary therapies, such as reflexology and massage, spiritual care both for people who are religious and others provided by chaplains and a social work service and welfare  benefits advocacy, advocacy, to help people sort out their finances, which are often disrupted by serious illness. After death, the social work service and chaplaincy provides  bereavement care to families and carers. The Hospice also has an education centre  providing courses for its staff, for the t he locality, nationally and internationally; we are the largest provider of palliative care training in the world. The principle of our  education is that learning about our professional work must be based firmly on  practice.  Sources of knowledge

There are a number of sources of knowledge relevant to the Hospice, used by  practitioners to acquire knowledge to use in their practice. Each of these sources involves different kinds of partnership with other organisations. The National Health Service, in particular its public health function, local councils and organisations such as the Office for National Statistics provide knowledge at the level of population statistics and area data. Research findings, government guidance and reports provide authoritative data based on a focused study of information. These might come from  partnerships with researchers, and organisations such as university departments depart ments as well as government. The skill and experience of the workforce provide less comprehensive, perhaps more qualitative information, but knowledge that is directly relevant to the needs of patients and professionals as they work together. This involves professional contacts and meetings, relationships with local l ocal and community  partners, and involvement in joint activities such as education and conferences. Thus, more formal knowledge interacts with informal knowledge and understanding to influence practice.

 

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That interaction is not unproblematic, since while in principle these sources of  knowledge add to each other, knowledge always represents the interest of the organisation than produces and disseminates it. For example, the Department of  Health, the government ministry, seeks to use knowledge to push policy n desired  political directions. Professional organisations may have projects to press forward, incorporating a wish for influence for their position. Information sources are also an important influence on the direction of knowledge. For example, the Office of   National Statistics finds it difficult to collect census information from some part sof  the community, community, particularly minority minorit y ethnic groups and people who do not wish to be identified in official data gathering activities. These forms of knowledge become incorporated into the organisation’ organisation’ss work through different processes. For example, the Hospice is a member of national bodies concerned with co-ordination of organisations working in palliative care, Help the Hospices and the National Council for Palliative Care. Through working parties, conferences and joint projects, knowledge and understanding can be developed. Partnerships with government are also often achieved through such joint processes, by which practitioners can influence government policy and practice, by lending their  expertise tot the development of guidance and regulatory practice. For example, recently the National Council organised a joint working party to identify varying costs in different aspects of services aimed to move towards a more standardised framework for managing finances, which in turn will affect how the National Health Service allocates funding to hospices nationally. nationally. The periodic publication of  information from the ten-yearly population census allows the calculation of  deprivation indexes for different areas area s of the country, and for understanding about the numbers of people from different ethnic minority groups in the area served by the Hospice, so that it can respond to different cultural needs. Government guidance and regulation affects how practitioners interpret their work, and practitioners’ interpretations eventually influence government guidance. This process of incorporation is also not unproblematic and a smooth incorporation of  knowledge cannot be taken for granted. For example, different sized hospices have different interests in funding, and so cost analyses can provoke conflict between organisations in membership of co-ordinating bodies. For the members, the t he benefits from involvement and influence have to be balanced against disadvantages in  participating in an agreed view that may not always benefit the particular  organisation. Partnerships in research are organised in different ways. Sometimes, members of staff  develop a research project on their work, and will work with colleagues form a local university in carrying it out. Staff who attend higher degree courses ay universities supervised by university staff carry out research for their dissertations in the Hospice, or students placed at the Hospice will carry out research on their work as part of their  dissertation for their award. Sometimes the Hospice will contract with a university department to carry out a piece of research in which it has an interest. For example, the Hospice has recently awarded a grant to a local university to study the ways in which service users perceive complementary therapies to be beneficial. Sometimes a university will approach the Hospice on behalf of a PhD or other researcher who needs access to its patients to carry out a project. For example, a PhD researcher from Ireland, based at a university in the Netherlands has recently used the Hospice as a

 

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source of subjects for an international qualitative study on how service users perceive the shift from curative to palliative care. Sometimes the Hospice will negotiate a strategic piece of research with a university department or the university will agree a  joint project to pursue research as part of its own programme – funding for projects is more easily obtained from some sources if it involves both university and practice agencies. For example, the Hospice has recently been involved in a project examining the use of an outcome scale as part of its staff’s practice. It is also working with a university on a project to train nurses to carry out cognitive-behavioural therapies; the research is examining whether the short training in CBT is effective and whether this improves outcomes for service users. However, to discuss this process as ‘partnership’ conceals competition and conflicting interests that may also exist. An agency such as a hospice might benefit from or seek  to downplay particular research findings, or give access to research perceived to  benefit its particular view, or deny access where the research might be disadvantageous. Professional groups may obstruct research that conflicts with their  interests. Thus, as with participation in co-ordination, partnerships in research for  knowledge creation may bring different interests into play. In any service, there are a number of these knowledge interests, individuals or  organisations that have a stake in how knowledge is both interpreted and used in  practice. An important recent document, the NICE guidance manual on palliative care for adults with cancer (NICE, 2004) illustrates this. It was produced by an independent organisation supported and promoted by government to give guidance on the most effective way of carrying out clinical practice in health care. To promote a  policy to improve services for adults with cancer, the government included this  project in NICE’s work programme. Research reviews were commissioned from authoritative researchers, some of whom worked on research at St Christopher’s, groups of practitioners and service users were consulted through various drafts, including staff from St Christopher’s, and the final document contains detailed guidance about what treatments are most effective according to research evidence and established practice. This guidance is multiprofessional: it i t includes social work. A similar organisation (the Social Care Institute for Excellence - SCIE) carries out the same function in social care, where social work is the main focus of a service. Involvement in knowledge development in any agency depends on a number of  factors that creates a more of less powerful role for it in knowledge development. A crucial factor is the history and record of research in the agency and in the professions that make it up. St Christopher’s started from research: the historic work of Dame Cicely Saunders in the 1950s in pain control was the origin of its foundation (Saunders, 1963, 2004). Many agencies were set up to implement legislation or the ideals and commitment of their the ir founders. An important way of developing research is to incorporate it as a crucial part of the organisation’s activities. Another important factor will be how research is managed: St Christopher’s has a clear research governance process, which helps people to understand how to take up research ideas and implement them. It has a representative research committee, which has a regular review of research ideas, puts them in priority and follows them up. Outside researchers approach the committee with their ideas, which can gain approval, and a senior manager is allocated responsibility for smoothing their path

 

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within the organisation, and organising ethical approval for research with patients and service users. An audit committee representing practitioners can then meet to discuss the practicalities of recruiting subjects for the research and carrying it out in the everyday work of the Hospice. This generates commitment to particular projects and helps staff understand why they are asked to collect information or work in a  particular way. The research committee also allocates a small research budget to internal projects, provides training and support in writing up and presenting results through academic and professional journals. While all this potentially benefits knowledge development more widely, widely, governance procedures also fform orm arenas in which particular kinds of research may be advanced or impeded by particular  interests. So, to understand knowledge development within an organisation, we must also explore the political processes through which interests have an impact on what knowledge is created and rejected. Carer and user involvement  Involvement in knowledge development by carers and users is an important source of  knowledge. It provides feedback on service quality, quality, it helps to t o obtain funding by demonstrating the effectiveness of the service and it gives patients and involvement and a sense of purpose as participants in the work of the Hospice, instead of their   being merely objects of care. It is also an important government priority that patients should have choice in the services they receive and influence on the management of  their care.

There are particular problems with carer and user involvement. Ultimately, people who are dying cannot tell you about their experience. Patients are often very ill, and it is hard to involve them in conventional information techniques. Since the service is intended to provide for a ‘good death’, bothering people for information can seem unethical. However, patients often appreciate being able to make a contribution to standards of care for people who will use the services after them. The research governance process is important here for identifying and dealing with the practical and ethical problems that may arise. It is also important to distinguish between user  and carer involvement, since the interests of service users may be different from the interests of their caregivers. Other problems may reflect a conflict in interest between users’ and carers’ concerns and professional or organisational concerns. For example, many patients say that they appreciate day care and complementary therapies as part of their treatment, such as massage, reflexology and acupuncture. However, the complexity of the social outcomes of such interventions means that they do not offer clear evidence of  achievement of political health care objectives. the NICE guidance (2004), for  example, does not propose enhancement of day care or complementary therapies for  this reason. In this way, knowledge development processes may conflict with user or  carer interests, and user and carer responses may implicitly criticise research achievements and priorities and policy based on this. Such conflicts can be uncomfortable to professionals and researchers. The Hospice uses three main processes for user and carer involvement: quality assurance processes as part of its clinical governance processes, a series of user  forums, and user user involvement in audit audit of particular services. These are considered in

 

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turn in the following sections, which give a broader overview of clinical governance as part of the process of creating knowledge from practice.  Knowledge for management: clinical governance Clinical governance is different from research governance, discussed above, but is another important way of generating knowledge from practice. Clinical governance  processes allow multiprofessional teams to collect knowledge from a range of sources

and make recommendations for future development. Monthly meetings of staff  involved in services to patients and their families are divided into two: a general meeting to ensure co-ordination and developing procedures and policies by agreement and a review meeting every two months, interspersed with meetings to co-ordinate specific aspects of the services. A variety of mechanisms are used to feed the experience of the Hospice into these committees, so that knowledge can be developed from within them.

User feedback  Feedback from users of services is crucial to the quality of services; it often gives insights into the experience of receiving services that professionals do not have; it identifies practical difficulties that often do not occur to staff. It may also provide evidence for seeking funding, partly because it is a government priority to pay attention to user choices and because other funders seek evidence of user satisfaction. Most important, the use of open discussion through user forums gives both users and staff a sense of involvement and participation in a joint endeavour. Particular aspects of the service offer different opportunities. For example, every few weeks a group of  attenders at the Hospice day centre take part in a ‘goldfish bowl’ in which they discuss their experiences, watched by a group of medical students who can then ask questions. This connects user experience with training, and the sessions are recorded and the discussion sued as the basis for a qualitative research project. The Hospice also gives all users and carers questionnaires, and these are also widely available around the Hospice. They are collated periodically, and a six-monthly report is prepared. This gives an indication of trends, since deterioration from the usually high satisfaction levels can be immediately detected and inquired into. Each individual comment can also be helpful, because an individual suggestion can give an idea about how to deal with an issue that might not have occurred to staff.

Comments, suggestions and complaints The Hospice is keen to learn from ideas and things that go wrong. It has an integrated comments, suggestions and complaints system because many people because complaining is not their overall reaction to the service they receive and they ‘do not want to cause any trouble’. Therefore, a positive approach to getting ideas and suggestions is important to allowing problems to emerge, and when problems emerge, it is important to have a positive ‘we aim to improve’ approach to responding to them, otherwise both patients and staff will try to suppress them. W Wee have an integrated form for suggestions, which are investigated by a middle manager and the responded to within a published, short timescale by senior managers. Comments and suggestions are diverted into ‘user ‘ user feedback’ in the clinical governance system. The outcomes of  complaints are recorded in a register and reported on to the clinical governance committee every six months, so that any trends and needs for wider action can be identified.

 

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This kind of approach, which responds positively to complaints rather than seeing them as an opportunity for criticising staff, is important in avoiding distortions arising from the recording effects discussed above.

 Audit  The Hospice also audits its work. Every department produces statistics and qualitative information about its work twice a year, for discussion in the clinical governance committee. Then, every department chooses an aspect of its work for more comprehensive audit every year. Part of the work may also be identified for  development work. Thus, everyday present practice is audited and this may lead to developments; often areas thought to need development will be audited to identify what approach should be taken to the prospective changes. In a recent example, the welfare benefits advocacy service that is part of the social work department was audited. A recording instrument was developed for staff to complete to identify the problems raised and work done in ttwo wo months of cases. A 10% sample of multiprofessional case records was reviewed by an independent member of staff to identify whether problems noted were identified and referred. Finally, it was noticed that there was a small number of complex cases involving a lot of work, and the case records for this work was analysed. The annual workload of the service was calculated from these samples, and difficulties in providing the service identified. The study showed a high workload, handled efficiently, and producing outcomes for clients that far outweighed the cost of providing the service. The complex cases analysis identified the social security benefits that were producing the most problems. The case records review showed that potential referrers did not consistently identify even quite serious financial financia l problems among clients. The audit led to the allocation of another member of staff, validated staff and their achievements and strengthened support for the work. Another recent example was two audits on arrangements for discharge of patients from the Hospice. In different ways, these showed that this was happening efficiently and without problems. However, the feedback when this outcome was reported to nurses, was that they experienced the process as very stressful. So, a project was set up to examine precisely what caused aggravation in discharge.

Clinical events analysis The Hospice brings together three elements of review of clinical events, to learn from them: learning reviews, critical incidents and clinical reviews. Learning reviews are regular meetings to discuss cases, from which learning points are drawn and reported. There are multiprofessional events, and specialist events. Critical incidents are where there is a major event in a patient’s treatment, often where a risk arose, for example when a frail person falls, or where someone attempts suicide. A meeting of those involved is chaired ‘from the top down’ by an independent manager to find out  precisely what happened and report on learning. Clinical reviews arise ‘from the  bottom up’, where a difficult or complex situation was dealt with. Again, a meeting of  those involved is called to identify learning. Reports from all these sources are accumulated and reviewed annually; this allows learning to be drawn from events, without criticising people for what went wrong, although if things went well, the meetings often apportion praise.

 

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 Ethics panel  The Hospice maintains an ethics panel. This is separate from the research ethics management process, and examines and develops understanding about ethical issues faced in practice. It has both internal and external members from a range of   professionals, but includes external specialist ‘ethicists’. The Panel reviews and reports on events that raised ethical issues, to develop learning, and examines policies and initiatives that might raise ethical problems. Teams Teams of two or three t hree independent  people, drawn from the Panel, can be called on to act as consultants if there is a difficult decision to be made: the outcomes are then re-ported to the Panel, so that ethical guidelines can be improved.  Knowledge for development  So far, I have been discussing how knowledge from practice practi ce is constructed to emerge from practice through various organisational processes. In doing so, I have noted some of the ways in which conflicts about priorities and perspectives may emerge in the organisational processes through which such knowledge emerges form practice. Many of the same processes also contribute to development, and also produce the same kinds fo conflicts of interest. Development includes the emergence or creation of new services or new aspects of services, achieving improvements in how present services are delivered and increasing knowledge and understanding through research and education as a way of providing a foundation for further improvement. An important area of conflict of interest here may derive from the need for championship of innovation as a way of achieving public and financial support for the organisation conflicting with the need for dispassionate analysis of outcomes.

Impetus for development may come from practice experience and research identifying where interventions work or do not work, pushing people to change their practice in the future. It may also come from the mission and vision of an organisation (Payne, 2000, ch 4), which may draw attention to failings in coverage or ethical and practice issues that require attention. It may also come from the impact of policy, particularly government policy, policy, and professional ideas on an organisation and its practice. Policy developments often reflect changes in social attitudes or expectations and an attempt  by people with social power to incorporate them into the practice of organisations. Development is often approached by research and evaluation. For example, staff in the Hospice’s day care centre were concerned because external researchers had questioned the value of day care as an element of palliative care service. Research discerned few clear outcomes form day care. Therefore, they used the ‘goldfish bowl’ user forums, discussed above, as a way wa y of identifying users’ objectives. Complementary therapists responded to other professionals’ comment that while  patients said they liked reflexology or massage, it was unclear why, or whether they might be helped equally or better by other interventions or ordinary social experiences. Therefore, the Hospice financed a study to identify precisely why  patients valued complementary therapies and how this compared in contributing to their well-being with their medical treatment and other well-liked social experiences. However, such approaches to research to ‘prove what we know’ or to present an organisational message make it difficult to understand how organisational interests may be interacting with research outcomes.

 

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Another way of achieving development is by setting up an innovative service, based on new opportunities. For example, the day care centre established a project for   patients to use new digital technologies to create artistic expression of their  experience of illness and their lives. These are often placed on a website http://www.rosettalife.org/)) provided by a co-ordinating and a nd development (http://www.rosettalife.org/ organisation in this field. This is an extension of the kind of experience provided by art or craft activities, updated with attention a ttention to modern technology, which may engage some service users more than the traditional technologies. Development may also be achieved through training and management systems. For  example, many staff were anxious about working with patients with mental illnesses –  anxiety and depression are common in dying people (Henderson, 2004; Hotopf, 2004). The Hospice established established a three-day training course, with a concentration on  practical skills, to increase confidence and understanding. It then established a system whereby a member of each multiprofessional team went on the course and then acted as a consultant and supporter to other team members as they dealt with particular  difficulties among their patients. Conclusion Our professional knowledge for management and development emerges from our   practice in agencies. I have suggested that this cannot just be assumed to happen, an agency must establish processes by which knowledge can emerge and be formulated in ways that can be practised and used. But as it does so, it will also incorporate into organisational structures for research and knowledge governance, conflict or  competition between knowledge interests for control of the knowledge creation  process, and in turn for the outcomes of knowledge development.

Knowledge can only be developed in partnerships, because there are many people with knowledge interests, stakes in the information used to create knowledge, and  particular roles. Among the most important sets of relationships, r elationships, however, are  between agencies and higher education e ducation institutions. However, these have substantial differences in interest. Consequently, Consequently, claiming ‘partnerships’ as a taken-for-granted approach to co-operation conceals the potential difficulties. As with all co-operative mechanisms, knowledge develop usually requires careful work, so that interests are aligned and conflicts defused. The source of agency approaches to knowledge development tends to be their vision and mission, while the mission of a university if  knowledge development. What brings them together is practice: practi ce: universities develop knowledge to influence the real world, the world of practice, while agencies aim at improved practice as the main objective of their knowledge development. Agencies nowadays are often multiprofessional, whereas universities are typically discipline based. Again, Again, it is how people from different disciplines practi practice ce in relationships with other professionals that allows knowledge development to have a wide impact on services. Small research projects can be carried out by practitioners in agencies and as small projects in universities, but large projects will always require the combined expertise and commitment of a partnership between university and agency. agency. There are conflicts in priority that different knowledge interests may give to particular  knowledge, forms of knowledge and uses to which it may be put. In particular, partic ular,  powerful interests, such as government, may not be interested in applications of  knowledge to practice, but only in its policy or management potential. This means that

 

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 professional knowledge relevant for practice may have a lower priority for many organisations. Consequently Consequently,, it may ma y be important for social work agencies to identify identif y  partnerships in which professional and practical knowledge can be made more  powerful in the battle for knowledge influences. Knowledge from practice can be made powerful for management and development by  being relevant to a range of members of the multiprofessional teams, by drawing on the perspectives of users and carers, and adding to that partnership a range of different knowledge interests. Because the partners inevitably have different interests, there will be conflicts of priority. Sometimes, the objective of influence on practice in the field can unite universities, agencies, practitioners and carers and users in a  partnership for better practice, better management and renewed development in social work services. Alternatively, Alternatively, the need to influence practice in the direction of   particular knowledge interests can generate conflicts and difficulties in knowledge relationships which requires careful analysis, understanding and effective structures of  research governance to overcome.

 

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