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Stayingontrackinchanginglandscapes_mappingcomplexprojectsinhealthservices.pdf

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ORIGINAL PRACTICE DEVELOPMENT AND RESEARCH

Staying on track in changing landscapes: mapping complex projects in health services

Hellen Dahl*, Kristin Ådnøy Eriksen*, Marianne Hauge Wennersberg, Sølvi Heimestøl and Brendan McCormack

*Corresponding authors: Western Norway University of Applied Sciences, Bergen, Norway Email: [email protected] and [email protected]

Submitted for publication: 20th March 2019 Accepted for publication: 27th June 2019 Published: 13th November 2019 https://doi.org/10.19043/ipdj.92.003

Abstract Background: Projects initiated to transform and develop health services have to account for a variety of complex factors. There is a need to develop methods to handle this complexity, and in this article we present a flexible and adaptable framework for mapping projects that focus on involvement of persons receiving care and other stakeholders, with an integrated support structure. The method also considers elements in the local context. Aims: To present examples of project mapping, and to explore how the process can enhance quality in complex projects in healthcare services. Methods: The project mappings have been co-designed in processes of deliberate dialogue between the authors of this article, with involvement from other researchers and stakeholders. A three- dimensional version of project mapping was developed, and further refined by introducing a two- dimensional version and testing the framework in various settings such as a project leader course and the 2018 Enhancing Practice Conference in Basel. Analysis continued through the whole process as preliminary ideas were discussed and documented. We reflected, wrote notes, talked to people, took part in workshops that included a variety of creative methods, and did a qualitative content analysis of key findings to develop themes. Results: The examples of project mapping show that the process of mapping is as important as the map itself. The maps are flexible and can be combined. Project mapping can contribute to quality in projects by helping project facilitators and participants to stay on track. It can also enable co-creation and guide facilitation processes. Conclusion: Engaging in mapping processes represents an approach that can contribute to a shift in thinking and help even out power imbalances between project participants, as well as influencing the working culture in a health service. Mapping can facilitate transformation of practice while simultaneously creating new knowledge about that transformation. Implications for practice:

• Project mapping takes account of the complexity of changing practice in healthcare settings • It offers project teams a novel way to engage in understanding project processes and outcomes • It acts as a reminder that aims for quality improvement should be guided by health and wellbeing

for persons receiving care, rather than being systems related

Keywords: Project management, project mapping, complexity in health services, person-centred, stakeholders, transforming practice cultures

International Practice Development Journal

Online journal of FoNS in association with the IPDC and PcP-ICoP (ISSN 2046-9292) Working together

to develop practice Person-centred Practice International Community

of Practice

Background Effective healthcare services are dependent on paying attention to continuous quality improvement, and one indicator of quality is involving patients and service users (Norwegian Directorate for Health and Social Affairs, 2019). The Norwegian government wanted to strengthen the position of the patient in the healthcare system by ensuring that their voice is given greater consideration (Norwegian Ministry of Health and Care Services, 2015). Quality is also associated with services that are coordinated (Norwegian Directorate for Health and Social Affairs, 2019), which means transforming ways of collaboration between specialised health services and primary care, as well as expectations of cooperation between the professions.

Systematic efforts intended to raise the quality, safety and value of healthcare services (Ogrinc et al., 2015) are often handled through projects, or short-term endeavours (Aarseth, 2014) to create improvement. The healthcare domain is highly complex (Klein and Young, 2015) for many different reasons. In this article, we focus on the diversity of stakeholders whose views and activities are central to healthcare (Klein and Young, 2015) and in particular the need to involve patients and service users in project planning. Attention also needs to be paid to the context, understood as ‘the key features of the environment in which the work is immersed and which are interpreted as meaningful to the success, failure, and unexpected consequences of the intervention’ (Ogrinc et al., 2015, p 503).

In this article, we suggest that project descriptions need to be clear, tailored to their unique context and customised to the persons involved in order to ensure momentum and direction. We describe a flexible and adaptable project map that can help to handle complexity in ‘soft projects’ – those that aim to change or transform health services in which human beings and processes of working are crucial (Hussein, 2016, p 25). Each project is different, as it is dependent on and is ‘marked by human interactions in a complex dynamic’ (Hussein, 2016, p 70). Von Schomberg (2012, p 9) suggests a need for transparent and interactive processes, and that all participants should become mutually responsive to each other.

Project management is not ‘a destination, but an ongoing journey that demands keeping people loyal to the vision, and constantly striving for its attainment even during periods of adversity’ (Aarseth, 2014, p 23). In order to become involved, a person needs to be given a clear picture of the project’s aim, and its plans need to be comprehensible (Hussein, 2016, pp 59, 85). Flexibility and non-formal processes provide opportunities for creativity (Hussein, 2016, p 85), and there is a need for sensitivity to the context and valuing of different forms of knowledge (Long et al., 2018).

Research produces important knowledge regarding healthcare, and projects may aim to use this knowledge in clinical practice. This implementation and adoption of new knowledge is not a linear path or a straightforward process. There is no proven recipe to follow; it is the very opposite of ‘one- size-fits-all’ model (Harvey and Kitson, 2015). There is a need to tailor interventions to the local contextual circumstances (McCormack et al., 2010; Øye et al., 2015) and consideration must be given to factors like organisational climate and the need for multifaceted support that will influence the use of new knowledge (Meijers et al., 2006). Flexibility is also needed to accommodate fluctuations in staff enthusiasm, service culture and patient response (Dahl et al., 2018).

A collaborative approach and ongoing communication seem to contribute to successful implementation of interventions (Diffin et al., 2018). This kind of approach is associated with ‘real team membership’, which has been found to be beneficial for individual outcomes and organisational performance (Lyubovnikova et al., 2015 p 929). The team needs awareness of shared objectives, and continuous improvement depends on engagement in team regulatory processes (Lyubovnikova et al., 2015).

There are several methods and frameworks that guide projects in health services. The framework for design, execution and evaluation of complex interventions to improve health – the UK Medical Research Council framework – aims to ensure quality in all phases of designing and evaluating a project

(Campbell et al., 2000; Blackwood, 2006). The Context and Implementation of Complex Intervention (CICI) framework addresses and graphically presents context, implementation and setting, and aims to simplify and structure complexity (Pfadenhauer et al., 2017). This article’s authors have experience with practice development methodology (Dewing and McCormack, 2017; Manley, 2017), the i-PARIHS framework as well as the person-centred practice framework (McCance and McCormack, 2017). We suggest there is a need for supplements to these frameworks that can guide frontline practitioners in projects, with particular regard to the work of tailoring to local context, as well as ensuring real participation. The creation of project maps may help to handle the physical and sociocultural makeup of the local environment (Ogrinc et al., 2015; Sugiyama et al., 2017). This includes keeping track of issues such as aims, stakeholders and interactions in order to gain an overview and decide on the next steps in the project. Attention to the fluctuating human processes of co-creation of plans for ongoing developments is crucial for the quality of the project.

The aim of this article is to present examples of project mapping, and to explore how mapping can contribute to the enhancement of quality in complex projects in healthcare services.

The term ‘facilitator’ has been chosen for the person guiding the mapping process. We are aware that this may be a project manager, an external facilitator or an ad hoc facilitator, depending on the organisation of the project. The term ‘co-design’ refers to the method used and processes involved in ‘designing’ the mapping framework. The term ‘co-creation’ refers to the processes of using the mapping framework – that is applying the mapping framework to specific projects.

Methods The project maps were co-designed through processes of deliberate dialogues between the authors of this article, with involvement from other researchers and stakeholders with an interest in the research area. This co-design methodology enhanced utility, transparency, and saliency of the research (Future Earth Transition Team, 2013).

The process of this co-design (described in Table 1) started at a creative workshop with the theme ‘Evaluation and research in practice development projects’. In group work, participants spoke of projects as having a lot of ‘loose ends’ and conflicting views of interest, as well as of a need to gain an overview of their projects, decide what the next step could be and work with ideas for evaluation. To understand the issues better, a three-dimensional map (using objects including Lego, lengths of wool, feathers, a woodpecker and Evoke cards) was created (Figure 1). This was a representation (or a map) of one particular project at the time, as understood by the group. Even so, this map made sense and was recognisable to participants in the workshop who had not taken part in making it.

Figure 1: Three-dimensional map

Figure 2: Two-dimensional illustration of the project map

Who are involved/stakeholders? What are their tasks? How do they work? Documentation: What and how to document? Models, pictures, minutes, summaries, plans, data for evaluation...

Project title:

This triggered an interest in further work with exploring how mapping processes could be useful beyond the particular project. After the seminar, the authors started the process of co-designing a two- dimensional illustration of the project map (Figure 2). This illustration provides an overview of main aim/objective and stakeholders in a project (who, what, how and documentation). Facilitators in local healthcare projects subsequently tested the model. Deliberative dialogues and preliminary reflections and analysis continued and led to further questions as we explored and gained understanding of the significance of the project map. We used a questionnaire to ask facilitators and others for feedback on how this type of project mapping could be useful, and we also asked for suggestions for development or change. The steps in the process of co-design, overview of the data material and details about the participants in the co-design processes are described in Table 1.

Table 1: Co-design process and overview of data material

Research questions, developed through co-design

How the deliberative dialogues were organised

Data

How to handle and get overview of a complex project?

• Creative workshop • Three-dimensional map of one specific project

• Framework with lego, woodpecker, wool, etc

• Pictures

How can a two-dimensional project map be used to get overview of stakeholders?

• Local project • Example of project (with stakeholders and aims) in the 2D map

• PowerPoint example

Can the 2D model be useful in learning how to lead a project?

• Course for project leaders • Examples from project leaders that used the map

• Evaluation notes • Picture of example

Will experienced facilitators find the framework relevant?

• Presentation to colleagues • Questionnaires • Evaluation notes

Will experienced facilitators find the framework relevant? Does it add to tools they already know? How can it be useful?

• Basel Enhancing Practice conference 2018

• ‘Creative space’: presentation of framework, and participants creating implementation of the framework to the project

• Questionnaires from participants in creative space

• Audio recording of dialogue • Pictures of example • Picture of model created by

participants • Notes and reflections after the

conference

Will experienced facilitiators find the framework relevant? Does it add to tools they already know? How can it be useful?

• Basel Enhancing Practice conference 2018

• Pictures from ‘show and tell’ display • Questionares from participants • Notes and reflections after the

conference

How can we contribute to knowledge about project development and execution?

• Ongoing processes, reflections, workshops, writing, using the framework, seeking advice, teaching others, etc

• Notes, pictures, paper drafts

Analysis The analysis continued through the whole process, as preliminary ideas were discussed and written down. After the Basel conference, the authors developed themes through a qualitative content analysis according to Vaismoradi and colleagues (2016), shown in Box 1.

Box 1: Theme development through a qualitative content analysis (Vaismoradi et al., 2016)

Initialisation phase: Each of the authors gained an overall understanding of the data. We read the evaluation notes and reflection notes, looked at pictures and notes from workshops and listened to audio recordings. We looked for the main issues, highlighted meanings and made codes based on the material Construction phase: In a workshop we sorted the codes from the four authors into preliminary categories and subcategories. Based on this, we reflected on possible definitions and descriptions. We met several times during this phase to write, go back to the material, rewrite, reflect, and use Evoke cards – asking, what are the main issues in our article? Rectification phase: A literature search and reading were done to relate our findings to established knowledge, and the themes were decided Finalisation phase: The storyline was developed bearing in mind that the two versions of the project map, the process of co-design, and the findings representing experiences with using the maps may be confusing for the reader

The themes developed were: • Staying on track (getting an overview, knowing where and when to act, understanding influence

of stakeholders) • Processes of co-creation (involvement, giving room for all perspectives, language, culture) • Facilitation

In the findings and discussion section, we present the project mappings. Thereafter, we explore how project mapping can contribute to enhancing quality in complex projects, using the themes. We present examples and relevant literature.

Ethical considerations The participants in the workshop and the ‘creative space’ at the Enhancing Practice Conference were invited to participate in the co-design process. All participants signed an informed consent. They gave their permission to include the material in research activity – the notes and the answers to questions about the model, in addition to contributions to the group discussion. They were informed about the study and were able to withdraw at any time. The participants cannot be identified in the findings.

Findings and discussion Presentation of two- and three-dimensional project mappings The two-dimensional map (Figures 2 and 3) has the main aim at the centre, and also provides an overview of which stakeholders are involved in a project. For each stakeholder there are categories stating what their task is, how they work and how they document their work. Each stakeholder may have their own aim, but this is related to the main aim. There are no lines dividing the stakeholders, indicating that they are interrelated. It can also contribute to awareness of the position of each participant (or the stakeholder group he or she represents) and how stakeholders depend on and influence each other.

Figure 3: Two-dimensional map giving overview of stakeholders’ defined aims and activities

Minutes and summary Minutes

and summary

Summary

Summary and recorded

interview

ProjectMap Minutes, summary, field notes

Meeting every third

month

Meeting twice a year

Meeting monthly Smaller work groups Dedicated persons Meeting monthly

Smaller work groups Dedicated persons

Summary, different kind of material and

instructions Summary, different kind of material and

instructions

Members of project groups

and work groups

Group interview and presentations

at conferences Ensure that children who have

relatives with serious illness are cared forProject group

interdisciplinary and from all parts

Status Share knowledge, tools,

experience Evaluation Next step

Overview Coordination involving

all parts Systematic contact

with all involved parts

Develop structure, procedures, brochure, learning programmes

Share their experiences and

advice

Share their experiences and

advice

Communication Facilitation

Using relevant tools

Secure the prioritising of the

project Follow the project

Stakeholders – parents

Stakeholders – young people

Work group in hospital

Project manager

Steering committee

Work group in five municipalities

Project title What about ME when

mum, dad or another close relative is seriously ill?

Who are involved/stakeholders? What are their tasks? How do they work? Documentation: What and how to document? Models, pictures, minutes, summaries, plans, data for evaluation...

The three-dimensional map (Figure 1, p 4) may, in principle, be any shape, depending on what the group decides. As the participants use different artefacts to co-create and agree on what the map should look like, they are involved and given an opportunity to influence priorities, aims, tasks and roles. This may support a sense of ownership and feeling of responsibility for what happens in the project. As the frames of cooperation are different from those of a formal meeting, different perspectives are given room.

These two approaches to mapping projects are flexible and can be used at different intervals during the project period, to update and change the course if need be. Those participants who tested both 2D and 3D versions suggested that the 3D version should be used first. Working with the 3D version was understood as more useful in gaining involvement from all stakeholders from the very beginning of a project. They described this version as being like a piece of art that may involve metaphors, illustrations, drawings and other materials, and argued that this would be meaningful to those involved in its creation. After the 3D version is made, a 2D model can be created. This will function as a working tool with defined aims and activities, and represent a linear understanding but also an overview of the complexity of the project. It illustrates, for all involved, the responsibilities and varying tasks. Participants also suggested that the project group could come back to the three-dimensional version after some time, and develop it further to explore certain elements, or to become aware of changes and developments in the project.

The participants in the co-design process thought it would be helpful to engage a project group in co-creation of an image or a map of the project. These experienced facilitators had previously lacked a tool that could reflect the complexity in a project. Possible advantages may be handling issues like interrelatedness between persons, roles and tasks, non-linearity, giving people ownership, and staying on track while handling changes. A sense of ownership can increase the prospects of the project being sustained even when key people are no longer there.

Staying on track The findings indicate that mapping projects can contribute to a project staying on track, at the same time as addressing its complexity. It can help to gain an overview in an ongoing journey of changing landscapes. Mapping processes in groups encourages and opens up opportunities for involvement, and perspectives from all stakeholders can be included. The participants develop ownership and experience the project as being dependent on their contributions; they can see their own contribution as a part of a collective endeavour to achieve a common aim. The flexibility in the mapping process can support non-linear processes and reflect fluctuations in human interactions, and the use of creative methods and informal dialogues leads to opportunities to discover elements that are important in defining and describing the issues at stake in the particular context.

Many of the participants in the co-design process emphasised the importance of 2D mapping placing the person receiving care at the centre. They argued that project aims are often defined without their involvement, with the result that those aims might comply with the needs of the organisation rather than of patients.

To illustrate how the project map has been used, we present two cases. In one case, involving primary and specialised healthcare services, a project was established in line with new national guidelines (Norwegian Ministry of Health and Care Services, 2015) on how services should care for children who have a relative with a serious illnesses. The project had two facilitators, one external and one internal, who used the project map to gain an overview of the stakeholders that should be involved and what their roles and responsibilities in the project should be. The aim was noted in the middle of the two- dimensional map. It became apparent to the facilitators that the group at which the project was aimed – young people whose relatives have a serious illness – were not included in the project group. The local youth council, established by the specialised health services, was therefore asked for advice and members were invited to share their experiences of being siblings or children of persons with serious illness. In hindsight, the facilitators realised that the whole group would have benefited from an active use of the map throughout the project. The two-dimensional map could have been altered or given more details according to what was shared by the stakeholders, or a new map could have been made to give an overview of the status of a particular stage of the project.

Another project in the primary care setting used a different approach. The project manager decided to use a map throughout the project. The map being was developed in collaboration with the project group, which made use of it at every meeting. The project map was even hung on the office wall as a reminder of each participant’s role and responsibility.

As other project facilitators gained access to the tool, their response was that it gave a valuable overview of projects, and helped their project groups to show the complexities. One group used it every time it met and experienced it as helpful to hold on to the aim and to stay on track.

Traditionally, project planning and work has focused on predestined outcomes and process fidelity (Long et al., 2018). Mapping projects represents an approach that values the contributions of the persons involved in a project, focusing on continuous learning and development of ‘local knowledge’. These processes support a shift from thinking of project work as about fulfilling a mandate or set of standards, to the more dynamic approach of understanding a project as travelling through changing landscapes. The project and the persons involved need to handle changing circumstances as projects are not linear and the healthcare services they set out to change are multi-layered.

Processes of co-creation The co-creation work can bring awareness about travelling together in the journey of project work. As participants co-create and agree on what the project map should look like, they are involved and have opportunities to influence priorities, aims, tasks and roles. This promotes a sense of shared ownership and responsibility for what happens in the project. As the frames of cooperation are different from those of formal meetings, different perspectives are privileged. This can encourage participation from persons who may not be used to giving their opinion in a group setting. Speaking together while ‘playing’ with blocks and pictures to create a common product makes it easier to build relationships. In some cases, it may contribute to levelling out power imbalances, as contributions to the mapping can be made by anyone, irrespective of status or level of education. As the mapping does not focus on definitions and a linear description of a project, it can be a way of involving persons who are not comfortable with reading and writing.

The mapping process can also help to reveal complexities in the context, such as tensions in relationships between stakeholders or tacit issues. Awareness of enabling and prohibiting factors in the context can emerge as the different participants reveal their thoughts and perspectives. For example, artefacts may be used in the mapping to generate metaphors that make sense to the group; they may represent factors that are hard to describe or define but are significant and worth exploring in handling the complexity of a project. In one workshop, the participants chose to name one stakeholder group ‘the tigers’. This was part of the humour in the group as well as representing something recognisable for the participants – something to be afraid of, someone to respect or someone with a lot of power. Another group used a woodpecker toy to convey the idea of someone continuously ‘pecking’ as a reminder about the project’s aims and tasks. Such metaphors may be a way of revealing culture, including local knowledge and understanding of ‘how things are done around here’.

Creating metaphors, revealing attitudes and naming underlying, unspoken issues in the culture is a development of knowledge about the local context, contributing to collective sensemaking and understanding (Greenhalgh et al., 2016). People are different and some participants may experience discomfort regarding reading and writing. Titchen and Hammond (2017) contend that dialogues using the spoken work alone can be restricting and that the use of creative expression can help overcome this. They argue that embodied knowledge may not reach conscious thoughts. Co-production and co- creation may make it possible to become aware of some of this knowledge.

Speaking together about the work can bring surprises, as people realise others’ thoughts are different to what was assumed. Narratives about what we do and how we do it contribute to enhanced

confidence in own work and pride on behalf of the team (Eriksen and Heimestøl, 2017). Kaplan et al. (2012) associate success in quality improvement with groups of people who have previously worked together in teams. Getting to know each other in ways that include humour and playfulness can help diffuse tension and eradicate barriers. Thriving in each other’s company is linked to trust and may lead to individuals experiencing being ‘free to learn, risk, make mistakes and grow’ (Manley et al., 2011, p 8). Sustainable change depends on mutual trust, built over time (Greenhalgh et al., 2016).

According to national guidelines (Norwegian Ministry of Health and Care Services, 2015), development of health services that belong to the ‘patient’ requires changes in culture, attitudes, organisation and leadership. Patients and those close to them should be agents of change, and structures that privilege professionals’ claims to knowledge should be removed. This points to a need for methods that challenge power hierarchies. In all landscapes of practice there are competing voices and competing claims to knowledge (Wenger-Trayner and Wenger-Trayner, 2015, p 16), so ensuring involvement in co-creation processes offers an approach to moving out of the ivory tower and closer to the real world (Greenhalgh et al., 2016, p 421).

Involving persons in this way in defining and deciding tasks in a project may influence the way professionals work together. They become more able to address implementation barriers and accustomed to ongoing communication and proactive problem solving. They get used to being ‘part of a culture where there is legitimacy for changing practice’(Diffin et al., 2018, p 1). Microsystems that emphasise teamwork, communication, freedom to make decisions and commitment to improve have been associated with success in quality improvement (Kaplan et al., 2012).

Facilitation For project mapping to achieve its potential benefits, there is a need for someone to initiate and plan the processes. The role of the facilitator did not surface as a key issue in the findings, and we contend that this ‘invisibility’ of the facilitator may be consistent with the underpinning philosophy of the mapping framework (co-ownership and co-creation). Thus the facilitator’s role is not one of director of activity, but instead is that of a co-participant with the additional responsibility for paying attention to consistency of process.

Inviting participation in creative activities is not a straightforward process. The facilitator needs to be sensitive to resistance and to the readiness in the culture, and consider interventions or preparations before embarking on co-creation. This way of working can represent a disruption to a working culture, and the consequences can be positive or negative, leading to development and growth, or the process getting out of hand and becoming unmanageable. However, the presence of a ‘trigger’, explained as ‘a specific event (positive or negative) that stimulates a new emphasis on improving quality’ (Kaplan et al., 2012, p 18) has been found to be key to success in quality improvement. Having to reconsider what one does and thinks may evoke awareness and lead to new perspectives and understandings (Eriksen et al., 2014). There is potential for development and change through seeing different perspectives and being taken out of safe and established routines. Tensions may arise and can be obstacles, but they can also present new opportunities to spur creativity (Wenger-Trayner et al., 2015, p 101). This may nonetheless be a challenging position for the facilitator, requiring a clear vision of the purpose and mission of a person-centred healthcare service.

Thus, we contend that the role of the facilitator in project mapping is consistent with that of transformational facilitation (Titchen and McCormack, 2008). The key processes are associated with those of consciousness raising, problematisation, self-reflection and critique in a group (Titchen and Hammond, 2017). When facilitated, mapping processes can contribute to conscious awareness of taken-for-granted assumptions; they can influence culture and language, and be a way of co-creating and contesting new knowledge and understanding (Titchen and Hammond, 2017, p 165). Thus, the ‘being’ of the transformational facilitator as evidenced in the mapping processes enables the surfacing of participants’ knowing, doing and becoming, which brings together critical and creative engagement

as we seek to understand and facilitate the transformation of practice and, simultaneously, create new knowledge about that transformation.

Critical reflections We believe that the mapping process can be a way of involving persons receiving care and their significant others. We further emphasise that professionals’ voices sometimes compete with voices of persons receiving care. At the same time, the co-design processes seem to have contributed to this imbalance by only involving professional healthcare workers, facilitators and researchers. We feel this is because co-design was about developing a tool for facilitators and professionals, as it is their responsibility to initiate projects for quality improvement. Our hope is that facilitators choosing to use project mapping will be helped to keep the interests of the person receiving care in focus, and to involve them and those close to them at all stages of the project.

Conclusion We recommend that our methods for mapping projects be tested in other contexts and projects. We believe the two- and three-dimensional versions can be used together and separately, depending on the participants and processes in the particular project. Mapping projects in these ways can contribute to insight and consistency of process. The process may be hindered by a lack of courage to initiate transformative processes and avoidance of tensions and issues that are hard to manage. Engaging project groups in mapping activities represents a different approach that can contribute to a shift in thinking, even out power imbalances and influence the working culture in a healthcare service. Further, this way of working provides a helpful tool to assist project management and improve quality in complex projects in healthcare. Facilitating mapping processes involves the ability to judge when and how to implement the framework, awareness of interpersonal processes and cultures, and readiness to adapt to changes in the context of the project.

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Acknowledgments The authors would like to acknowledge the contributions of participants at the Enhancing Practice Conference 2018 in Basel to the design of the mapping framework.

Hellen Dahl (MSc, RN, BN), Associate Professor, Western Norway University of Applied Sciences, Haugesund, Norway. Kristin Ådnøy Eriksen (PhD, MSc, RN, BN), Associate Professor, Western Norway University of Applied Sciences, Haugesund, Norway. Marianne Hauge Wennersberg (MSc, RD), Head of Research and Development Unit for Collaboration in Healthcare (FOUSAM), Western Norway University of Applied Sciences, Haugesund, Norway. Sølvi Heimestøl (RN, BN), Research and Development Advisor FOUSAM, Coordinator of Network for Learning and Mastering in Helse Vest, Haugesund, Norway. Brendan McCormack (DPhil Oxon, BSc Hons, FRCN, FEANS, FRCSI, PGCEA, RMN, RGN), Head of the Divisions of Nursing, Occupational Therapy and Art Therapies; Head of the Graduate School; Associate Director, Centre for Person-centred Practice Research, Queen Margaret University, Edinburgh; Professor II, University of South East Norway, Drammen, Norway; Extraordinary Professor, Department of Nursing, University of Pretoria, South Africa; Professor of Nursing, Maribor University, Slovenia; Visiting Professor, Ulster University.

A commentary by Professor Angie Titchen follows on the next page

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