Adult Learning Theory

Abstract ‘Facilitation’ is a concept frequently referred to as a strategy for enabling the process of devel- oping nursing practice. However, despite its frequent usage and importance to the development of practice, ‘facilitation’ in a practice development context is poorly defined and there is a scarcity of literature relating to this specific use of the concept, which has previously been explored in relation to the role and function of facilitation in evidence-based practice (Harvey et al. 2002). However, practice development is broader than the implementation of evidence- based practice (Unsworth 2000) and here the aim is to add to the understanding of the concept for ‘practice developers’ with diverse role remits.

Key words: development, evidence-based practice, ‘facilitation’, nursing practice

Introduction The process of concept analysis is a strategy for clarifying vague concepts that may be employed to fulfil several objectives, such as:

� clarification of ambiguous or terms � the development of operational definitions � the explication of problems for research or theory construction � the development of research instruments and nursing diagnoses (Walker and

Avant 1988).

To understand what is meant by the term ‘facilitation’ in a practice development context, concept analysis is required to determine its defining characteristics.

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‘Facilitation’ of practice development: a concept analysis

Research and review

Maxine Simmons—Head of Education and Workforce Development, Chesterfield & North Derbyshire Royal Hospital NHS Trust, UK

Practice Development in Health Care, 3(1) 36–52, 2004 © Whurr Publishers Ltd

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‘Facilitation’ has been identified as a critical element of practice development (Kitson et al. 1998), and a clearer understanding of the concept will support the effec- tiveness of ‘practice developers’. The concept has previously been explored in relation to the role and function of ‘facilitation’ in evidence-based practice (Harvey et al. 2002); however, practice development is broader than the implementation of evidence-based practice (Unsworth 2000), and here the aim is to add to the under- standing of the concept for ‘practice developers’ with diverse role remits.

‘Facilitation’ has been identified as a critical element of practice development (Kitson et al. 1998) and a clearer understanding of the concept will support the effectiveness of ‘practice developers’.

Practice development The challenges laid out within The NHS Plan (DoH 2000) highlight that changes in service delivery are a priority in order to meet the requirements for delivering healthcare, both now and in the future. However, whereas the responsibility to deliver patient care is accepted without question, there appears to be more ambivalence about the responsibility to develop that care (Kitchen 1997). Practice development is seen as a separate and optional activity to practice (Clarke and Proctor 1999), and, seemingly, the number of roles dedicated to developing practice has soared since the early 1980s (Glover 1998; Swan 1998).

However, ‘practice development’ itself appears as equally poorly defined as ‘facilitation’. Kitson (1994) provides one of the few definitions of ‘practice devel- opment’ as:

a system whereby identified or appointed change agents work with staff to help

them introduce a new activity or practice. The new practice may come from the

findings of rigorous research; findings of less rigorous research; experience which

has not been tested systematically trying out an idea in practice. The introduction

of the development ought to be systematic and be carefully evaluated to ensure

that the new practice has achieved the improvements intended.

A further definition is provided by Mc Cormack et al. (1999), who state that:

Practice development is a continuous process of improvement towards

increased effectiveness in patient-centred care through the enabling of nurses

and health care teams to transform the culture and context of care. It is enabled

and supported by facilitators committed to a systematic, rigorous, continuous

process of emancipatory change.

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Unsworth (2000) identifies four critical attributes of practice development:

� New ways of working, which lead to a direct measurable improvement in care or service to a client.

� Changes that occur as a response to a specific client need or problem. � Changes that lead to the development of effective services. � The maintenance or expansion of business or work.

However, there is little evidence that these definitions reflect the reality of practice development. In a study by Garbett and McCormack (2001), staff perceived ‘practice development’ as being more aligned to professional development and personal practice changes rather than as changes to the culture or context within which they worked.

Here, the ambiguity of the term ‘practice development’ is acknowledged, and all uses of the concept have been incorporated into a literature review.

Concept analysis The concept analysis framework provided by Walker and Avant (1988) was used, which, although presented in a linear fashion, is based on eight interlinking stages:

� select the concept � determine the aims or purposes of an analysis � identify all uses of the concept � determine the defining attributes � construct a model case � construct borderline, related, contrary, invented and illegitimate cases � dentify antecedents and consequences � define empirical referents.

This framework has been criticized for being reductionist and resulting in a loss of practical application (Morse 1995). However, a reductionist approach was seen as beneficial in the present case, to separate the term ‘facilitation’ from other related concepts, and to aid clarity.

Concept selection and aim of the analysis Walker and Avant (1988) emphasize the importance of selecting a concept that is specific and can be defined, and which—most importantly—is of interest to those undertaking the analysis. The aim of the analysis was to:

� explore the use of the term ‘facilitation’ in practice development � identify the defining characteristics of practice development ‘facilitation’ � identify similarities and differences between ‘facilitation’ in practice devel-

opment and other contexts.

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Literature review Walker and Avant (1988) recommend that a literature review should be extensive, and that all uses of the concept, including dictionary definitions, should be included in the initial analysis.

A literature search was undertaken using the CINAHL database. The search strategy involved searching for texts that included in their title the words ‘facili- tator’ and ‘facilitation’, with 31 and 67 citations available, respectively. A further search, expanding the search word ‘facilitate’, produced 1345 references, which were then combined with the following subject headings and produced the corre- sponding references:

� learning theory or learning (28) � change (213) � practice changes (9) � theoretical models (15) � nursing practice, research-based (14).

The expanded ‘facilitate’ word search was also combined with a journal search of the Journal of Advanced Nursing (66 citations) and the Journal of Clinical Nursing (5 citations); it was anticipated that articles in these journals would contain quality analyses and significant references to enable further cross-referencing. Dictionaries and texts were also reviewed.

Uses of the concept

Definitions

In education, ‘facilitation’ has been referred to since the 1960s and is used consistently throughout the literature to describe a specific process, with clear elements and a role definition of a ‘facilitator’. However, within nursing practice the term has become part of practice development terminology and is used to describe a range of activities and processes. No definitions of ‘facilitation’ were identified within practice development literature, and in the main, the term is used without explanation of its specific meaning. Kitson et al. (1998) argue that ‘facilitation’ along with the nature of evidence and context is one of three key elements required for effective practice development, and these authors suggest that it is perhaps the most important element where environ- ments are not conducive to change. However, their description of ‘facilitation’ derived from educational, not practice development literature, where ‘facilitation’ is used both as a term to describe a specific process within a group context and also as an umbrella term to describe a multitude of strategies used to promote change. The dictionary definition of ‘facilitation’ was ‘to make easy or easier’ (The Oxford Colour Dictionary and Thesaurus 1996).

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The literature review identified a number of uses of ‘facilitation’, which were categorized into eight areas:

� physiological � psychological � social � professional development � educational � research � occupational � clinical practice.

Physiological

‘Facilitation’ in this sense is prevalent within rehabilitation literature (Burke et al. 2000; Holcomb 2000). However, ‘facilitation’ is a term also used in a wide variety of other clinical contexts from midwifery to maxillo-facial and respiratory medicine, to speech and language therapy. The Longman Concise Dictionary (1985) definition of ‘facilitation’ reflects this physiological meaning of the concept as ‘the ease with which an impulse is conducted along a nerve’.

Psychological

‘Facilitation’ as a method for group counselling is noted by Burrows (1997) and Otis-Green (2000). Rogers’ (1969) therapeutic counselling background was the impetus for his later application of ‘facilitation’ to education through the development of his student-centred approach, and the subsequent adoption of the concept into present-day adult education.

Social

‘Facilitation’ is seen to be grounded in the co-operative movement, which is based on ensuring that everyone in a group can, if they wish, participate fully in decisions that affect them (Hunter et al. 1996). ‘Facilitation’ is a process to make things easier or more convenient, with the ‘facilitator’ guiding the group towards a destination (Hunter et al. 1996).

Professional development

‘Facilitation’ is used frequently in relation to professional development, and has also been linked with mentorship for students (McLain 1999). Thornbory (1999) describes a specific Royal College of Nursing (RCN) professional ‘facilitator’ role, with a remit to actively promote continuing professional development in the workplace. In addition to promoting learning opportunities, ‘facilitators’ are also reported to have a role in delivering education directly (Astrop 1988; Sharpe and Atkinson 1999).

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Education

‘Facilitation’, which is now part of mainstream education, was introduced into education during the 1960s, and stemmed from the work of Carl Rogers (Rogers 1951; Cross 1996). Heron (1989) describes six dimensions of ‘facilitation’ in education (planning, meaning, confronting, feeling, structuring and valuing) and provides expla- nations of how to behave in each, using what he describes as three decision modes: direction, negotiation and delegation.

A concept analysis of ‘facilitation’ in education by Cross (1996) and Burrows (1997) identified the defining attributes of ‘facilitation’ as illustrated in Table 1. Burrows (1997) also provides a tentative definition:

Facilitation is a goal-orientated dynamic process, in which participants work

together in an atmosphere of genuine mutual respect, in order to learn through

critical reflection.

Research

‘Facilitation’ is a technique that has been used both within research and research supervision. Soltis-Jarrett (1997) describes how the researcher in participatory action research acts as a ‘facilitator’ to guide and promote discussions. The ‘facilitator’ in participatory action research shares authority and maintains a balance of power. This notion reflects the philosophy of the aforementioned co-operative movement. The role of the ‘facilitator’ as research supervisor has been described as creating a supportive climate, helping with administration and the development of the research proposal (Harrison and Kitchen 1989), which is more closely aligned with educational ‘facili- tation’.

Occupational

‘Facilitation’ is an alternative to traditional change-management models with the potential to guide, structure and smooth the processes involved (Duffy and Griffin

‘Facilitation’ of practice development 41

Table 1. A concept of analysis of ‘facilitation’ in education

Cross (1996) Burrows (1997)

Process Process of enabling change A dynamic, goal-orientated process

Nature of the process

Environment Climate for learning The development of a partnership in learning

Genuine mutual respect

Learning The practice of critical reflection

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2000). The use of ‘facilitation’ to bring about change is illustrated by Baker et al. (1995), where significant improvements in multidisciplinary involvement, and commitment to projects, were reported when ‘facilitators’ were employed compared with projects without them.

Within healthcare, and in particular within nursing, ‘facilitation’ was used in relation to ‘facilitation’ of change, integration of services and to promote communi- cation between organizations (Baker et al. 1995; Thornbory 1999; Maggs and Biley 2000). Change included the initiation of good practice and multiprofessional audit. It has been suggested that teachers should ‘facilitate’ the implementation of valid research findings and act as change agents to promote, support, ‘facilitate’ and evaluate change in practice. These suggestions are supported by Maggs and Biley (2000), who highlight the importance of ‘facilitation’ to develop research and innovation in clinical practice.

Other aspects incorporated within this included ‘facilitating’ meetings where the objective was the completion of a project and development of services. Bennett- Woods (1997) suggests five areas involved in project ‘facilitation’ of service devlopments:

� leadership � organizational politics � technical processes � interpersonal relations � team administration.

A further occupational dimension of ‘facilitation’ was to integrate services or facilitate contact between organizations (Sharpe and Atkinson 1999).

Clinical

Durgahee (1996) reports how nurses participating in a post-registration specialist course applied ‘facilitation’ techniques learnt during their studies into their practice areas, with increased insight into clinical practice and greater engagement of patients in decision-making as a result. ‘Facilitation’ has also been applied to patient care in the delivery of patient education (Sharpe and Atkinson 1999).

Defining characteristics As described by Walker and Avant (1988), a list of provisional criteria was identified. The provisional criteria were developed from identification of the characteristics of ‘facilitation’ that were identified in the literature (Table 2). The provisional criteria included ten categories which, after further analysis, were refined to five defining characteristics (Table 3). The refined list was developed through immersion in the literature and identification of the context in which the ‘facilitation’ was being described.

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Table 2. Provisional criteria defining ‘facilitation’

Characteristic Presentation Reference

Critical thinking Enabling practitioners to see the components that Durgahee (1996)

make up a situation; critical thinking

Foster a critical questioning approach; Gerrish (1992)

promoting research mindedness

Introduce issues Baker et al. (1995)

Negotiation Negotiation Sharpe and Atkinson (1999)

Agreeing responsibilities Duffy and Griffin (2000)

Shared decision-making Hunter et al. (1996)

Encouraging collaboration Duffy and Griffin (2000),

Durgahee (1996)

Task-orientated Developing systems or processes Baker et al. (1995)

Joint consultations with practice nurses; Sharpe and Atkinson (1999)

compiling data

Leading meeting Bennett-Woods (1997)

Resource Provide a professional resource; awareness Thornbory (1999)

of CPD initiatives and where to seek expertise

Focus for information Maggs and Biley (2000)

Specialist resource Sharpe and Atkinson (1999)

Cross-pollinator of good ideas Astrop (1998)

Act as a resource Gerrish (1992)

Make easier or Make easier or Hunter et al. (1996)

more convenient more convenient

Preparing for change Identify enthusiasts Astrop (1998)

Diagnose barriers to change Duffy and Griffin (2000)

Providing a purpose Durgahee (1996)

Equity Valuing all group members equally Baker et al. (1995)

Communication Distribution of plans Sharpe and Atkinson (1999)

Help teams to discuss issues Baker et al. (1995),

Astrop (1998)

Dissemination of information or innovations, Astrop (1998),

or deliver presentations Baker et al. (1995),

Thornbory (1999),

Maggs and Biley (2000)

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Critical thinking

Critical thinking is a key element of ‘facilitation’ referred to in educational literature. Educational theorists reflect the element of critical thinking within attributes of ‘facili- tation’, such as confronting (Heron 1989), questioning (Rogers 1983; Townsend 1990) and critical reflection (Brookfield 1986). Burrows’ (1997) definition of ‘facilitation’ includes critical reflection as an integral element of enabling students to learn. Within practice development literature, critical thinking is related to enabling individuals to see the components that make up a clinical situation (Durgahee 1996). It has also been suggested that nurse teachers have a role within the clinical setting to foster a critical questioning approach and to promote ‘research-mindedness’. Strategies used by ‘facili- tators’ to promote critical thinking include introducing issues (Baker et al. 1995) and the use of problem-solving techniques (Jacavone et al. 1999; Otis-Green 2000).

Shared decision-making

The attribute of negotiation reflects the shared decision-making described in education literature. Rogers (1983) and Townsend (1990) also use the term ‘negotiation’, whereas others have termed this attribute ‘participation’ or ‘collaboration’ (Brookfield 1986; Heron 1989). An example of shared decision-making is provided by Sharpe and Atkinson (1999), who describe how a diabetes ‘facilitator’ identified areas for service development through negotiations with a primary care practice. Agreeing responsibil- ities and encouraging collaboration and shared decision-making were seen to be central elements of ‘facilitation’ in a practice development context (Durgahee 1996; Hunter et al. 1996; Duffy and Griffin 2000). Where change is the aim, ownership of the devel- opment and a feeling by individuals that they have contributed to the final decision is

Simmons

Table 3. The five defining characteristics of ‘facilitation’

Provisional criteria Context Defining characteristics

Critical thinking Critical thinking

Communication Communication and negotiation were used in the Shared decision-making

Negotiation context of reaching agreement

Helping people by Helping people and acting as a resource were Making easier

doing particular tasks identified as strategies facilitators used to make

Acting as a resource it easier for staff

for others

Making easier

Managing groups Following review of the leadership literature these Leadership of change

Preparing for change three essential leadership criteria for effective change

Providing a purpose were identified

Equity Equity

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reported in change management literature as essential to promote not only initial acceptance of the change but also to ensure its long-term success.

A prerequisite for shared decision-making is communication, which was the most prevalent criterion to emerge from the literature. Communication is seen as central to the engagement of all stakeholders in the practice development process. Communication incorporates listening to the opinions and contributions of individuals in order to capture expertise (Jacavone et al. 1999). The element of listening to all stakeholders illustrates the importance of equality in the ‘facilitation’ process. However, more commonly, communication is used in the context of promoting discussion (Astrop 1988; Baker et al. 1995) and dissemination of infor- mation and innovations via minutes, documents, reports and presentations to stakeholders (Bennett-Woods 1997; Sharpe and Atkinson 1999; Maggs and Biley 2000). The preparation and dissemination of information is predominantly the role of the ‘facilitator’, possibly because of limitations of time and the skills of individuals involved in the group. However, this is an area where ‘facilitators’ in particular could promote ownership of practice development through enabling others to develop formal communication skills and by increasing empowerment.

Making easier

Personal definitions collated by Burrows (1997) from 18 of his peers identified the most common use of ‘facilitation’ as ‘to make easier’. ‘Facilitation’ has also been described as a process that makes it easier or more convenient to reach an agreed destination with the potential to smooth the processes involved in new ways of working (Hunter et al. 1996; Duffy and Griffin 2000).

Unlike educational ‘facilitation’, ‘facilitation’ in practice development has a task element. Tasks included: leading meetings (Bennett-Woods 1997); developing systems and programmes (Baker et al. 1995; Jacavone et al. 1999); and assessment and monitoring of care and data collection (Astrop 1988; Sharpe and Atkinson 1999). Sharpe and Atkinson (1999) also report undertaking joint clinical consultation with practice nurses. Townsend (1990) and Rogers (1983) identify that the teacher as ‘facilitator’ has a role to provide resources. Similarly, Bennett-Woods (1997) also suggests that the ‘facilitator’ of practice developments also has a role in locating resources. However, more commonly, the term ‘resource’ refers to the attribute of ‘acting as a resource’. ‘Facilitation’ of practice development can be promoted by a ‘facilitator’ who provides a focus for nurses to obtain the information they require to pursue a professional or practice development goal (Thornbory 1999; Maggs and Biley 2000).

This pragmatic element of ‘facilitation’ in a practice-related setting reflects the limited time clinical staff have to complete much development work themselves. Without a ‘facilitator’ to complete tasks, timescales may become elongated, missed or momentum for the project may be lost. However, this attribute, although ‘making it easier’ for individuals to pursue their goals and possibly maintaining the impetus and motivation for practice development, may unwittingly deny individuals an opportunity

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to develop critical skills and knowledge, for example literature-searching skills. This has obvious implications for the empowerment of individuals and suggests a paternal- istic culture.

Leadership of change

Preparation for change includes identifying barriers to change (Duffy and Griffin 2000) and recognizing enthusiastic individuals (Astrop 1988). Bennett-Woods (1997) identifies the role of the ‘facilitator’ in understanding organizational politics and guiding change through potential organizational obstacles; being aware of opportu- nities that will support the project, and its successful implementation.

Providing a purpose is key to providing structure to ‘facilitation’. Bennett- Woods (1997) identifies that the leadership aspect of ‘facilitation’ involves providing a sense of purpose that reflects a shared vision. Providing a sense of purpose may be achieved through a ‘facilitator’ who maintains focus during group discussions (Otis- Green 2000). For example, in a study by Durgahee (1996), nurses undertaking a post-registration course identified that they wanted their teacher to provide them with answers to their questions and were frustrated by the indirect use of ‘facilitation’ as a learning strategy. Durgahee (1996) concludes that ‘facilitation’ needs to provide a structure for purposeful activity, which applies equally to clinical situations where nurses may be using ‘facilitation’ to help patients to adapt to a change in their health status.

Heron (1993) describes group dynamics in detail and provides strategies for ‘facilitating’ different situations within a learning context. Similarly, the management of groups was an attribute identified in practice development literature, in relation to the ‘facilitator’ needing to be aware of, and able to manage, group dynamics as well as deploying strategies to help groups with problem-solving and decision-making (Hart 1992; Hunter et al. 1996; Jacavone et al. 1999). However, in a practice development setting, although a group of individuals may be working together on a practice devel- opment, operational restrictions often make it difficult to ‘facilitate’ practice development as a group. ‘Facilitators’ may be required to meet each group member individually to maintain project momentum. The attributes involved in one-to-one or work-based ‘facilitation’ are not discussed in the literature. This is potentially an important area of theory deficit as the ‘hidden’ work ‘facilitators’ may undertake between group meetings—supporting and encouraging individuals and trouble- shooting—that may be key to the successful implementation of a practice development, is not known.

This was the area of the analysis that created the greatest difficulty, as leadership theory, change theory and ‘facilitation’ of practice development were seen to be closely related concepts. Leadership is fundamentally about continuously ‘moving forward’ and ‘changing’, and without effective leadership change is unlikely to be successful. Practice development is fundamentally concerned with change, and many of the attributes of effective ‘facilitation’ (such as developing critical thinking in others, shared decision-making and treating individuals with equity) are all leadership attributes.

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From the literature it is not clear how these related concepts have been differ- entiated, or indeed if they have been or should be. It is also possible that ‘facilitation’ is used as a softer term than ‘change’ to infer that the process is collaborative, which may not be the case. Individuals may describe all that they do as ‘facilitation’ because their job title includes the term ‘facilitator’, although in practice they may use strategies other than ‘facilitation’ to promote change. These discrepancies were problematic during the concept analysis, but more importantly, raised questions relating to how the term ‘facilitation’ has, apparently without question, become integrated into the practice development vocabulary. This raises the need for further research to under- stand what individuals who develop practice mean when they describe an activity as ‘facilitation’, and how this activity manifests itself in practice.

Equity

The attribute of genuine mutual respect is viewed as an essential element in the ‘facili- tation’ of learning to enable students to share tentative ideas and express uncertainty or sudden insights (Burrows 1997). This is an attribute that is less explicit within the practice development literature, although the term ‘respect’ is used in relation to the importance of respect for other group members and respect for individual expertise (Bennett-Woods 1997; Jacavone et al. 1999). Instead, the related concept of ‘equity’ was identified. This involved valuing all group members equally: enabling and encour- aging equal opportunity to contribute (Baker et al. 1995; Hunter et al. 1999). The dictionary defines ‘equity’ as ‘fairness and impartiality’, whereas ‘respect’ is defined as ‘admiration or esteem’ and implies consideration, courtesy and politeness (The Oxford Colour Dictionary and Thesaurus 1996). Although the dictionary definitions illustrate the difference between ‘equity’ and ‘respect’, it is probable that these terms are applied synonymously in practice. In practice development literature, ‘equity’ may reflect the importance of this attribute in a setting where group dynamics are potentially influ- enced by the positional status of different group members and the need to consciously promote ‘equity’ to enable contributions from all members to be enabled and valued equally. This may be achieved by building trust among team members by emphasizing their unique roles and the importance of each member (Bennett-Woods 1997). This is arguably less of an issue where students are all equal in relation to each other on a given course, and is therefore not highlighted as a critical attribute within the educa- tional context.

Antecedents and consequences

Identifying antecedents and consequences helps to clarify critical attributes and any underlying assumptions (Walker and Avant 1988). ‘Antecedents’ are those events or incidents that must occur before the occurrence of the concept, whereas ‘conse- quences’ are those that occur as a result of the concept (Walker and Avant 1988). Table 4 details the language used within the literature to describe the skills used in the ‘facilitation’ of practice development.

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The antecedents of ‘facilitation’ were identified as:

� Competence of the ‘facilitator’ in: communicating information; interpersonal relationships to be able to support individuals; helping and enabling skills; critical thinking to be able to challenge assumptions; technical skills to be able to act as a resource and educator; assessment and evaluation skills; leadership skills.

� An environment that enables individual contributions to be sought. � Access to a clinical environment in which to develop practice. � Intrinsic or extrinsic drivers for change to provide a purpose.

Tentative suggestions as to the consequences of ‘facilitation’ are proposed, as there is minimal literature on which to base the outcomes of practice development. The conse- quences of facilitation were identified as:

� Stakeholders develop ownership of the practice development and achieve consensus decision-making (Baker et al. 1995), interdependence and empow- erment.

� Practice development objectives are achieved. � Individuals develop critical thinking skills.

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Table 4. The language used within the literature to describe the skills used in the ‘facilitation’ of practice

development

Language Context

Promoting Promoting research-mindedness

Leading Lead meetings

Fostering Foster a critical questioning approach

Developing Development of critical appraisal skills

Developing systems or processes

Introducing Introducing issues

Enabling Enabling practitioners to see the components that make

up a situation

Providing Providing a professional resource

Acting Acting as a resource

Assessing/Monitoring/Evaluating Assess and monitor the way care is organized

Helping Help teams to set objectives or discuss issues

Help nurses to be more pro-active

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� Individuals develop confidence in the practice development process and feel less anxious about future change or leading change themselves.

Model and additional cases

Walker and Avant (1988) suggest that model and additional cases should be constructed to clarify the concept further.

Model case

A model case is a ‘real-life’ use of the concept, and reflects all the critical attributes and no attributes of any other concept (Walker and Avant 1988):

Sister Davies is concerned that on her ward there is an increasing frequency of

administration of drug errors. She wants to see if this can be improved and

discusses her anxieties with the Practice Development Adviser (PDA). The PDA

enables the Sister to talk about what she sees as perhaps being the problem and

helps her to critically reflect on what may be the underlying causes. The Sister

has a number of ideas about how to improve practice. Before taking any action

the PDA undertakes a review of the literature looking for similar situations and

best practice solutions. The summary of the literature search is shared with the

Sister who along with the PDA discusses it with staff at a ward meeting

dedicated to this issue. The PDA uses probing questions to challenge assump-

tions and encourages all staff to contribute to the discussion, and agree an

action plan. The PDA discusses the proposed action plan with other stakeholders

to gain their support and promote their ownership of the change through the

inclusion of their contributions into the final action plan.

Each of the critical attributes is represented in the model case. Leadership of change is demonstrated by providing a clear purpose for the meeting. Equity is ensured through enabling all stakeholders to participate to the discussion. The practice development adviser acts a resource for specialist advice, which ‘makes it easier’ for staff to gather the information they need to inform their decision. Critical thinking is promoted through helping staff to challenge their assumptions. Shared decision-making is highlighted through discussions with external stakeholders.

Related case

A related case is similar to the concept being studied but does not possess all the critical attributes:

Following a review of the literature, Practice Nurse Clark undertakes an audit of

her nurse-led asthma clinic measuring local patient outcomes against national

benchmarks. The findings are presented at the practice audit meeting and a

change in practice agreed. The change in practice is subsequently implemented

by the practice nurse.

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The practice nurse has demonstrated leadership, shared decision-making and critical thinking skills. However, the practice nurse has been alone in the implementation of this project and has not ‘facilitated’ anyone else.

Contrary case

A contrary case contains none of the defining attributes of the concept and provides an example of what a concept is not:

The trust is concerned about the prevalence of patient falls. The trust employs a

clinical risk adviser to collate information about trends in incidents and

complaints.

This case has none of the defining attributes of ‘facilitation’ and does not result in a practice development.

Empirical referents

‘Empirical referents’ are categories of actual phenomena that demonstrate the occur- rence of the concept itself (Walker and Avant 1995). The concept analysis highlighted that ‘facilitation’ of practice development is an intangible phenomenon that would be impractical to employ as an indicator in a research study. Alternatively, it is recom- mended that better understanding of the concept needs to be pursued through qualitative study. Suggested questions for further study are:

� Who are the ‘facilitators’ of practice? � Who do they ‘facilitate’? � What do the ‘facilitators’ do that ‘make changes happen’? � How do ‘facilitators’ describe what they do? � How do staff describe the experience of ‘facilitation’ compared with other

change management strategies?

Conclusion It is evident that ‘facilitation’ of practice development is a complex and important concept to practice developers. A clear definition of what is meant by the concept ‘facilitation of practice development’ remains elusive; however, this analysis adds to our knowledge about the diverse use of the concept in practice, and provides an insight into the skills and knowledge required by ‘practice developers’ to be effective in enabling change.

Both the concepts of ‘practice development’ and ‘facilitation’ are terms used loosely in practice and they describe a wide variety of operational activities. With the current drive for the modernization of healthcare services and the need for effective development of practice, shared understanding of what is meant by ‘practice devel- opment’ is essential to ensure that staff are clear about what is required. Evidence is

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required about the most effective strategies for enacting developments to enable staff to practise evidence-based change management. In order for ‘practice developers’ to base their practice on sound evidence knowledge is needed to articulate specifically the process of ‘facilitation’: how to ‘facilitate’ effectively in different situations, and when other change management tactics are more appropriate.

This concept analysis has highlighted a need for ‘practice developers’ to reflect critically upon their use of the term ‘facilitation of practice development’, to consider the terminology, and if this is an accurate means of describing a particular activity. Individuals need to be able to articulate what they are doing when ‘facilitating practice development’, in order to repeat elements that are effective and to share knowledge with others. If ‘facilitation of practice development’ remains tacit knowledge, embedded within the practice of a few individuals, the whole scale of change required to achieve modernization will be difficult to achieve and sustain. It is suggested that educators need to incorporate ‘facilitation of practice development’ and its associated skills into research utilization and management modules to enhance nurses’ skills and knowledge in this area. However, perhaps most imperative is the need for research into ‘facilitation of practice development’ and professional debate to share understanding of the concept and best practice to be disseminated.

References Astrop P. Facilitator—the birth of a new profession. Health Visitor 1988; 61: 311–12. Baker R, Sorrie R, Reddish S, Hearnshaw H, Robertson W. The facilitation of multi-professional clinical

audit in primary health care teams from audit to quality assurance. Journal of Interprofessional Care 1995; 9: 237–44.

Bennett-Woods D. Team facilitation skills: a step beyond running a good meeting. Journal of AHIMA 1997; 68: 20–3.

Brookfield SD. Understanding and Facilitating Adult Teaching: A Comprehensive Analysis of Principles and Effective Practices. Milton Keynes: Open University Press, 1986.

Burke DG, Culligan CJ, Holt LE, McKinnon WC. Equipment designed to stimulate proprioceptive neuro- muscular facilitation flexibility training. Journal of Strength and Conditioning Research 2000; 14: 135–9.

Burrows DE. Facilitation: a concept analysis. Journal of Advanced Nursing 1997; 25: 396–404. Clarke C, Proctor S. Practice development: ambiguity in research and practice. Journal of Advanced

Nursing 1999; 30: 975ñ982. Cross KD. An analysis of the concept facilitation. Nurse Education Today 1996; 16: 350–5. Department of Health. The NHS Plan. London: DoH, 2000. Durgahee T. Facilitation: the concepts in use in palliative care nursing. International Journal of Palliative

Care 1996; 2: 158–62. Duffy M, Griffin E. Facilitating Organisational Change in Primary Care. Oxford: Radcliffe Medical Press, 2000. Garbett R, McCormack B. The experience of practice development: an exploratory telephone interview

study. Journal of Clinical Nursing 2001; 10: 94–102. Glover D. The art of practice development. Nursing Times 1998; 94: 58–9. Harrison LL, Kitchen EK. Implementing the research facilitator’s role. Nurse Educator 1989; 14: 21–6. Hart L. The Faultless Facilitator. London: Kogan Page, 1992. Harvey G, Loftus Hills A, Rycroft-Malone J, Titchen A, Kitson A, McCormack B et al. Getting evidence

into practice: the role and function of facilitation. Journal of Advanced Nursing 2002; 37: 577–88. Heron J. Facilitation Handbook. London: Kogan Page, 1989.

‘Facilitation’ of practice development 51

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Holcomb WR. Improved stretching with proprioceptive neuromuscular facilitation. Strength and Conditioning Journal 2000; 22: 59–61.

Hunter D, Bailey A, Taylor B. The Facilitation of Groups. Basingstoke: Gower, 1996. Jacavone JB, Daniels RD, Tyner I. CNS facilitation of a cardiac surgery clinical pathway programme.

Clinical Nurse Specialist 1999; 13: 126–32. Kitchen SS. Research, the therapist and the patient. Journal of Interprofessional Care 1997; 11: 49–55. Kitson A. Clinical Nursing Practice Development and Research. Activity in the Oxford Region. Oxford:

Centre for Practice Development and Research, National Institute for Nursing,1994. Kitson A, Harvey G, McCormack B. Enabling the implementation of evidence based practice: a conceptual

framework. Quality in Healthcare 1998; 7: 149–58. Maggs M, Biley A. Reflections on the role of the nursing development facilitator in clinical supervision and

reflective practice. International Journal of Nursing Practice 2000; 6: 192–5. McLain W. Mentorship/facilitation for student nurses in Accident & Emergency, making a difference.

Accident & Emergency Nursing 1999; 7: 117–18. McCormack B, Manley K, Kitson A, Harvey G. Towards practice development—a vision in reality or a

reality without a vision. Journal of Nursing Management 1999; 7: 255–64. Morse JM. Exploring the theoretical basis of nursing using advanced techniques of concept analysis.

Advances in Nursing Science 1995; 17: 31–46. Otis-Green S. Facilitation key to stellar discussion groups. Patient Education Management 2000; 7: 94–5. Rodgers BL, Knalf KA. Concept Development in Nursing, Foundations, Techniques and Applications.

Philadelphia, PA: WB Saunders, 1993. Rogers C. Student Centred Teaching—Client Centred Therapy: Its Current Practice, Implications and

Theory. London: Constable, 1951. Rogers C. Freedom to Learn. Columbus, OH: Merril, 1969. Rogers C. Freedom to Learn for the 80’s. New York: Macmillan, 1983. Sharpe J, Atkinson R. The role of the diabetes facilitator in providing care. Community Nurse 1999; 15:

31–2. Soltis-Jarrett V. The facilitator in participatory action research. Les raisons d’être. Advances in Nursing

Science 1997; 20: 45–54. Swan L. Responding to change in developing nursing practice. Nursing Times 1998; 94: 59–60. Thornbory G. Professional facilitation. Nursing Standard 1999; 14: 1. Townsend J. Teaching/learning strategies. Nursing Times 1990; 86: 66–8. Unsworth J. Practice development: a concept analysis. Journal of Nursing Management 2000; 8: 317–26. Walker L, Avant K. Strategies for Theory Construction in Nursing (second edition). Connecticut, NJ:

Appleton & Lange, 1988.

Address correspondence to: Ms Maxine Simmons, Head of Education and Workforce Development, Chesterfield and North Derbyshire Royal Hospital NHS Trust, Calow, Chesterfield S44 5BL, UK.

Simmons

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