Adult Learning Theory

N U R S I N G T H E O R Y A N D C O N C E P T D E V E L O P M E N T O R A N A L Y S I S

Getting evidence into practice: the role and function of facilitation

Gill Harvey BNurs PhD RHV RGN DN

Director, Quality Improvement Programme, RCN Institute, Oxford, UK

Alison Loftus-Hills BA MSc BSW

Senior Research and Development Fellow, RCN Institute, Oxford, UK

Jo Rycroft-Malone BSc MSc RGN

Research and Development Fellow, RCN Institute, Oxford, UK

Angie Titchen MSc DPhil MCSP

Senior Research and Development Fellow, RCN Institute, Oxford, UK

Alison Kitson BSc DPhil RN FRCN

Professor and Director, RCN Institute, Oxford, UK

Brendan McCormack BSc DPhil RGN RMN

Professor of Nursing Research, University of Ulster and Royal Hospitals Trust, Belfast, UK

and Kate Seers BSc PhD RGN

Head of Research, RCN Institute, Oxford, UK

Submitted for publication 14 February 2001

Accepted for publication 11 December 2001

Ó 2002 Blackwell Science Ltd 577

Correspondence:

Jo Rycroft-Malone,

Quality Improvement Programme,

RCN Institute,

Radcliffe Infirmary,

Woodstock Road,

Oxford OX2 6HE,

UK.

E-mail: [email protected]

H A R V E Y G L O F T U S H I L L S A R Y C R O F T M A L O N E J T I T C H E N AH A R V E Y G ., L O F T U S -H I L L S A ., R Y C R O F T -M A L O N E J ., T I T C H E N A .,

K I T S O N A M C O R M A C K B & S E E R S K . ( 2 0 0 2 )K I T S O N A ., M c C O R M A C K B . & S E E R S K . ( 2 0 0 2 ) Journal of Advanced Nursing

37(6), 577–588

Getting evidence into practice: the role and function of facilitation

Aim of paper. This paper presents the findings of a concept analysis of facilitation in

relation to successful implementation of evidence into practice.

Background. In 1998, we presented a conceptual framework that represented the

interplay and interdependence of the many factors influencing the uptake of

evidence into practice. One of the three elements of the framework was facilitation,

alongside the nature of evidence and context. It was proposed that facilitators had a

key role in helping individuals and teams understand what they needed to change

and how they needed to change it. As part of the on-going development and

refinement of the framework, the elements within it have undergone a concept

analysis in order to provide theoretical and conceptual clarity.

Methods. The concept analysis approach was used as a framework to review

critically the research literature and seminal texts in order to establish the

conceptual clarity and maturity of facilitation in relation to its role in the

implementation of evidence-based practice.

Findings. The concept of facilitation is partially developed and in need of

delineation and comparison. Here, the purpose, role and skills and attributes of

facilitators are explored in order to try and make distinctions between this role and

Background

In 1998, a conceptual framework was presented which, it

was proposed, represented the interplay and interdependence

of the many factors influencing the uptake of evidence into

practice (Kitson et al. 1998). Developed from a number of

years’ experience in practice development, quality improve-

ment and research the multidimensional framework attempts

to represent the complexity of the change process involved in

implementing evidence-based practice also acknowledged by

other authors (Dawson 1997, Dopson et al. 1999, Ferlie

et al. 1999). Theoretical and retrospective analysis of four

case studies, which had been undertaken by the RCN

Institute led to the proposal that implementation is explained

as a function of the relation between evidence (research

evidence, clinical experience and patient preferences), context

(culture, leadership and measurement) and facilitation (char-

acteristics, role and style). The three elements – evidence,

context and facilitation – are each positioned on a low to high

continuum. We suggest that the most successful implemen-

tation occurs when evidence is scientifically robust (‘high’

evidence), the context receptive to change with sympathetic

cultures, appropriate monitoring and feedback systems and

strong leadership (‘high’ context), and when there is appro-

priate facilitation of change using the skills of external and

internal facilitators (‘high’ facilitation). The framework

considers these elements to have a dynamic, simultaneous

relationship and that in order to maximize the uptake of

evidence into practice the evidence, context and facilitation

continua need to be located towards ‘high’ (Kitson et al.

1998).

Whilst the framework appears to resonate with people’s

practical experiences of trying to embed new knowledge into

practice, the elements of evidence, context and facilitation

had not been subjected to a systematic analysis derived from

literature. As McKenna (1997) argues if a concept is unclear

then any work on which it is based will also be unclear.

Thus, as part of an on-going process of refinement and

validation and in order to provide some theoretical rigour

and conceptual clarity to the constituent elements of the

framework, a concept analysis of the dimensions evidence,

context and facilitation has been undertaken to determine

how each influences getting evidence into practice. This paper

presents the findings of the concept analysis of facilitation.

Introduction

Kitson et al. (1998) proposed that facilitators had a key role

in helping individuals and teams to understand what they

needed to change and how they needed to change it, in order

to translate evidence into practice. This involved facilitators

using a range of interpersonal and group skills to achieve the

desired change. From previous case study work three sub-

elements of facilitation were identified as being particularly

important in influencing the uptake of research into practice,

namely the personal characteristics of the facilitator, a

clearly defined role and appropriate styles of working. This

paper provides an analysis of the research literature in order

to achieve conceptual clarity about the concept of facilitation

in relation to its role in implementing evidence-based

practice.

Concept analysis method

This inquiry was conducted using Morse (1995) and Morse

et al.’s (1996) approach to concept analysis. This method is

particularly relevant to the concept analysis of facilitation

because it is more interpretive than the staged methods

described by, for example, Walker and Avant (1995) and

Rogers (1994), whose methods are located in a positivist

conception of objective truth (Morse 1995) and have been

criticized for de-contextualizing concepts (Morse 1995, Paley

1996). In contrast, Morse (1995) and Morse et al. (1996)

present a process of inquiry that establishes the develop-

mental stage or maturity of the concept(s):

...as revealed by their internal structure, use, representativeness, and/

or relations to other concepts. (1996 p. 255)

other change agent roles such as educational outreach workers, academic detailers

and opinion leaders.

Conclusions. We propose that facilitation can be represented as a set of continua,

with the purpose of facilitation ranging from a discrete task-focused activity to a

more holistic process of enabling individuals, teams and organizations to change. A

number of defining characteristics of facilitation are proposed. However, further

research to clarify and evaluate different models of facilitation is required.

Keywords: facilitation, change agents, evidence-based practice, research

implementation, practice development, concept analysis

G. Harvey et al.

578 Ó 2002 Blackwell Science Ltd, Journal of Advanced Nursing, 37(6), 577–588

For them, concept analysis entails an assessment process

using various techniques to explore the description of a

concept in the literature or from observation/interview data,

as opposed to the completion of specific stages described by

other concept analysis authors.

Morse (1995) and Morse et al. (1996) suggest that ideally

concepts in a discipline should be ‘mature’ meaning that a

concept is relatively stable, clearly defined, with well

described characteristics, demarcated boundaries, specified

preconditions and outcomes. In contrast, if a concept is

‘immature’ it will be poorly understood, poorly developed

and poorly explained. The aim of concept analysis is to move

the concept towards maturity. In terms of our work, the

concept analysis is being undertaken by an examination of

the literature. Therefore, the first stage in analysis is deter-

mining the concept’s level of maturity (1996). This paper

presents the findings of an in-depth analysis of the concept of

facilitation by describing its meaning, exploring its key

features and characteristics, and reviewing research into the

effectiveness of facilitation in relation to changing clinical

practice.

Search strategy

This review necessarily included an analysis of a broad

subject range of health care literature, as the literature

relating specifically to the role of facilitation in the imple-

mentation of evidence-based practice is limited. Conse-

quently, it focused on the use of facilitation within health

care, where an explicit facilitator role was adopted to

promote changes in clinical practice. Four databases were

searched (Medline, Cinahl, Pyschlit and Sociofile) for papers

published in English between 1985 and 1998. Key words

used were: facilita, education, audit and clinical audit,

quality improvement, quality assurance, change, change

management, behaviour, teamwork, group work and lead-

ership. In total 95 articles and books were included in the

review. These covered the role of facilitators in: primary

care, health care education, quality management and quality

improvement, audit, nursing management and teamwork.

Educational materials for training facilitators in standard

setting and audit, concept analyses, overviews of the facil-

itator role and books on the theory of facilitation were also

reviewed.

Characteristics of facilitation

The review indicated that for facilitation to exist as a discrete

concept, certain key elements need to be in place; including a

clear understanding of the facilitation process, an appropriate

role (the facilitator) to enable the process, with the right set of

skills to achieve effective facilitation. There are also questions

about the role of facilitation in relation to alternative

strategies or methods for implementation, as highlighted

above, in terms of how it compares to and is both concep-

tually and practically distinct from other change agent

strategies.

The findings of the concept analysis are structured around

the following key questions about facilitation:

• What facilitation is (meaning)? • What it is attempting to achieve (purpose)? • Through what sort of roles and in what ways (roles, skills

and attributes)?

• How does it relate to other change agent strategies? • What evidence there is of its effectiveness?

Origins and meaning of facilitation

Facilitation has been applied in different fields and disci-

plines, both within and outside health care, including educa-

tion, counselling, management, practice development, health

promotion, action research, clinical supervision, quality

improvement and audit. Kitson et al. (1998, p. 152)

described facilitation as ‘a technique by which one person

makes things easier for others’. This notion of ‘making easier’

is also reflected in the following dictionary definition (Oxford

English Dictionary 1989):

…to make easier, to promote, to help forward; to lessen the labour

of…

Within the field of evidence-based practice, there are other

strategies thought to be effective in terms of promoting

individual and organizational change. These include a

mixture of change agent roles and change management

techniques, for example, academic detailing, educational

outreach visits, audit and feedback, social influence and

marketing approaches. The research evidence suggests that

some of these approaches are effective in some situations and

that the most effective implementation strategies are those

that adopt a multifaceted approach, combining a number of

the most effective roles and techniques (Oxman 1994, Bero

et al. 1998).

In the context of this paper, facilitation refers to the

process of enabling (making easier) the implementation of

evidence into practice. The definitions suggest that facilita-

tion is achieved by an individual carrying out a specific role (a

facilitator), which aims to help others. This suggests that

facilitators are individuals with the appropriate roles, skills

and knowledge to help individuals, teams and organizations

apply evidence into practice.

Nursing theory and concept development or analysis Getting evidence into practice

Ó 2002 Blackwell Science Ltd, Journal of Advanced Nursing, 37(6), 577–588 579

Purpose of facilitation

The concept of facilitation appears to have emerged from the

fields of counselling and student-centred learning, influenced

largely by humanistic psychology and, in particular, Rogers’

(195122 , 1969, 1983) seminal work on therapeutic client-

centred approaches to counselling. In Roger’s work and

subsequent developments (see, e.g. Heron 1977, 1989,

Reason & Rowan 1981, Reason 198833 ), facilitation refers to

a process of enabling individuals and groups to understand

the processes they have to go through to change aspects of

their behaviour or attitudes to themselves, their work or

other individuals (Marshall & McLean 1988). Hence, the

focus is on facilitating experiential learning through critical

reflection, dealing with psychological defensiveness and

challenging cultural norms.

A similar interpretation of facilitation is apparent in some

approaches to practice-based learning in health care. For

example, facilitative learning approaches (including student-

centred, problem based and experiential learning) have been

applied within frameworks of reflective practice and clinical

supervision (Barrows & Tamblyn 1980, Titchen 1987,

Johns & Butcher 1993, Palmer et al. 199444 ), the aim being

to challenge existing practice and support the development

of new ways of working. An emphasis on experiential

learning, critical reflection and changing practice cultures is

also apparent in much of the literature on practice devel-

opment and action research (Ward et al. 1998, Binnie &

Titchen 1999, Jackson et al. 1999, McCormack et al.

1999). For example, in Titchen’s model of facilitation

described as critical companionship (Titchen 2000), clinical

and facilitation expertise are developed through experiential

learning. Here, the emphasis is on facilitating learning from

practice and, co-creation of new knowledge through critical

reflection, and dialogue between the practitioner (or learner)

and an experienced facilitator (the critical companion). The

role of the companion is to help individuals and groups of

practitioners to use the new theoretical insights to transform

self and social systems that hinder improvements in practice.

In other fields such as quality management and in some

health promotion activities, the purpose of facilitation

appears to be more concerned with the achievement of

specific goals. This is evident, for example, in the use of

facilitation methods in quality circles and total quality

management (Leventhal 1984, Moore & Kovach 1988,

Harvey 1993, Smith & Hukill 1994), or in some models of

health promotion such as the so-called ‘Oxford Model’

(Fullard 1994). Here, although the emphasis of facilitation

remains that of a helping process, this is more specifically

focused on the achievement of tasks or goals, as opposed to

exploring relationships at team and individual levels. For

example, the ‘Oxford Model’ of facilitation was established

in the early 1980s to introduce more systematic approaches

to coronary heart disease prevention and was applied as a

practical technique to support the establishment of systems

such as health checks and screening for high-risk patients.

Other approaches have adapted the ‘Oxford Model’ of

facilitation to support the implementation of clinical audit,

with perhaps a more explicit focus on teamwork than the

original approach (Hearnshaw et al. 1994). In a similar way

to the ‘Oxford Model’, audit support staff have been trained

to act as facilitators, applying a structured, collaborative

approach to enable the completion of the audit cycle (Carroll

1994). Indeed, as the original initiatives focusing on health

promotion activities have developed and expanded, there is

evidence of a widening interpretation of the facilitation

concept to address issues such as team-building (Baker et al.

1995, Loftus-Hills & Harvey 2000).

Many of the descriptions of facilitation in the literature

seem to suggest the existence of ‘hybrid’ models of facilitation,

which aim to balance the achievement of goals with the

development of individuals and group processes. For example,

in the Dynamic Standard Setting System (DySSSy) (RCN

1990) facilitation is identified as one of the key building

blocks of a method that aims to promote the local implemen-

tation of standards and audit. The facilitation approach is

adapted from Heron’s model of co-counselling and aims to

translate the core principles underpinning the DySSSy method

(teamwork, devolved responsibility, consensus decision

making and local ownership of quality improvement) into

practice. Facilitation is consequently focused on two key aims,

namely the achievement of specific goals (the implementation

of standards and audit in practice) and the development of

processes to enable effective teamwork (Morrell & Harvey

1999). Additionally, in practice development and action

research there is evidence that facilitation can encompass

different modes, providing a range of technical, practical and

emancipatory support during the change process (Jackson

et al. 1999, Titchen 2000, McCormack & Garbett 2001).

Overall our analysis suggests that the purpose of facilitation

can vary from providing help and support to achieve a specific

goal to enabling individuals and teams to analyse, reflect and

change their own attitudes, behaviour and ways of working.

These are not mutually exclusive and may be best represented

as extreme points on a continuum of facilitation (see Figure 1).

Descriptions of applying the concept indicate a combination of

approaches in use, often addressing different needs at the same

time. Here, examples of different approaches outlined above

have been located on the continuum, in terms of where they

focus particular attention (see Figure 1). As the approach

G. Harvey et al.

580 Ó 2002 Blackwell Science Ltd, Journal of Advanced Nursing, 37(6), 577–588

moves to the right, facilitation is increasingly concerned with

addressing the whole situation and the whole person.

The facilitator role

Just as the purpose of facilitation appears to vary within the

literature, there are also multiple interpretations of the

facilitator role in practice. These range from a practical

‘hands-on’ role of assisting change to a more complex,

multifaceted role.

In the models of health promotion which explicitly employ

a facilitator, the emphasis is on external facilitators using an

‘outreach’ model to work with several primary health care

practices, providing advice, networking, and support to help

them establish the required health prevention activities

(Fullard et al. 1984). By contrast, approaches to facilitation

that are rooted in the fields of counselling and experiential

learning are strongly influenced by underlying theories of

humanistic psychology and human inquiry. Consequently,

the facilitator’s role is concerned with enabling the develop-

ment of reflective learning by helping to identify learner

needs, guide group processes, encourage critical thinking, and

assess the achievement of learning goals. For example, in

some of the reported practice development initiatives, the

facilitator role is concerned with enabling cultural change in

organizations, through facilitating individuals and teams to

analyse and challenge current ways of working through

methods of reflection using action learning and mentoring

(McCormack & Garbett 2001). This often involves models of

external–internal facilitation, where facilitators from outside

the change setting work with identified internal facilitators,

using a range of support and supervisory methods to enable

the development of the internal facilitator’s own skills and

knowledge in managing change (Johns & Kingston 1990,

Binnie & Titchen 1999, McCormack & Wright 2000).

Heron’s (1989) model of facilitation incorporates facets

evident in both the outreach and practice development model

of facilitation. Whilst Heron emphasizes the facilitator’s role

in addressing issues of feelings within the group, confronting

resistance and giving meaning to group discussions, he also

acknowledges their role in planning and structuring the task.

In performing the role, Heron suggests that facilitators

operate in different ways at different stages, according to

the group’s needs and stage of development. This may require

the facilitator working in either a directive, co-operative or

nondirective way in any given change process.

It appears, therefore, that the operationalization of the

facilitator role depends upon the underlying purpose and

interpretation of the facilitation concept. Where the primary

purpose of facilitation is to achieve set tasks or goals, the role

is largely concerned with providing practical help and

support. However, where facilitation is focused more broadly

on developing and empowering individuals and teams, there

is at least an equal emphasis on the development of a helping

(enabling) process or relationship.

The central focus of the facilitator role has a corres-

ponding influence on the level and amount of support

provided by the facilitator. It also determines the number of

sites or organizations (coverage) they can work with and the

level of operation (individual, team or organizational). For

example, facilitators operating in an ‘outreach’ model

typically work across a large number of organizations,

whereas facilitators supporting a practice development

initiative may be appointed to work full-time within a

specific setting (for example an organization, unit or ward)

for a set period of time (Binnie & Titchen 1999, McCor-

mack & Wright 2000). It also follows that facilitators who

are attempting to improve group processes and change

existing cultures require a longer, more intensive period to

achieve their purpose.

In summarizing the literature of facilitator roles, it appears

that a broad distinction can be made between a facilitator

role that is concerned with ‘doing for others’ and a role

whose primary emphasis is on ‘enabling others’ (Loftus-Hills

& Harvey 2000). The ‘doing’ role is likely to be practical and

task-driven, with a focus on administrating, supporting and

taking on specific tasks where necessary. In contrast an

‘enabling’ facilitator role is more likely to be developmental

in nature, seeking to explore and release the inherent

potential of individuals. In reality, many approaches contain

elements of both these characteristics. Again, the range of

apparent roles can be presented along a continuum as

illustrated in Figure 2.

Facilitator skills and attributes

A diverse range of skills and personal attributes are

reportedly required to perform an effective facilitator role

(RCN 1990). This hardly seems surprising given the possible

Figure 1 Characteristics of facilitation.

Nursing theory and concept development or analysis Getting evidence into practice

Ó 2002 Blackwell Science Ltd, Journal of Advanced Nursing, 37(6), 577–588 581

myriad of purposes and roles the concept of facilitation

might encompass. However, there appears to be little

concrete evidence in the literature as to the mix and relative

importance of the different skills needed for the successful

performance of the facilitator role. Generally, it seems that a

mixture of personal attributes and personal, interpersonal

and group management skills contribute to the development

of effective facilitation. Table 1 illustrates this point by

summarizing the skills and attributes that have been iden-

tified from studies applying facilitation in three different

activity areas.

Just as there is little evidence to indicate the relative

importance of the different skills and attributes needed for

effective facilitation, there is also little clarity about how

facilitation skills are developed and refined. From the work

reported to date, it appears that most facilitators develop

their skills and styles of working through an experiential

process (Harvey 1993, Loftus-Hills & Harvey 2000). These

experiential processes can be either informal (for example, a

process of trial and error), or more formal and structured (for

example, through models of critical companionship or exter-

nal-internal facilitation (Titchen 2000). There is also some

evidence that facilitators move from a more direct support

role towards a more enabling one as their skills and

confidence develop (Harvey 1993).

Whilst there are core skills, such as interpersonal and

communication skills that are believed to be a prerequisite

requirement of any facilitator role, it appears that to be

effective, facilitators require a tool kit of skills and

personal attributes that they can use depending on the

context and purpose. In cases where the purpose of

facilitation is to achieve a specific, task-driven goal, the

skills and qualities used would be different from those

required to achieve longer term developmental goals, as

illustrated by the proposed continuum (see Figure 3).

Arguably however, the expertise could be in having the

flexibility to be able to recognize the requirements of an

individual situation. This may mean drawing on a combi-

nation of skills and qualities in the course of any change

process.

Figure 2 Role of facilitators.

Table 1 Skills and attributes required to be an effective facilitator

‘Oxford’ prevention model Quality improvement – DySSSy Practice development

Allsop (1990) Morrell et al. (1995) McCormack and Garbett (2001)

Supplying technical or

clinical advice

Networking

Empowering clinicians

Recognition of other’s skills and abilities

Local credibility

Being pragmatic

Risk taker

Belief in the worth and value of people

Offer suggestions Highly developed communication skills Patience

Formulate solutions Commitment

Help shift attitudes Harvey (1993) Having vision

Political skills Knowledgeable and up- to-date Being motivated

Vision Innovators Being empathetic

Energy Help with group dynamics Experiential

Fullard (1994) Understanding the system Titchen (2000)

Catalyst for change Lateral thinking Attending to whole person through use of self

Resource agent Sensitive Facilitating:

Helping hand

Teambuilding

Good communicator

Allowing people to learn by their

own processes

– cognition, meta-cognition, intuition

and their interplay

– use of different kinds of evidence

– particularization of research findings

Ability to create an environment of high support

and high challenge

Figure 3 Skills and attributes of facilitation.

G. Harvey et al.

582 Ó 2002 Blackwell Science Ltd, Journal of Advanced Nursing, 37(6), 577–588

Clarity between facilitation and other change agent roles

and strategies

Recent research has highlighted that human sources of

information are seen as influential because they provide

relevant, prescriptive, clinically focused messages for prac-

tice, tailored to the context of individual decision situation

and presented in a language that clinicians can understand

(Thompson et al. 2001a, 2001b). Similarly our concept

analysis has found that facilitation is a process that

depends upon a person carrying out the role of the

facilitator, with the appropriate skills and knowledge to

enable changes in practice. However, there are a number of

other change strategies that similarly depend on a person-

led intervention to support the change process. Those

commonly reported in the literature include educational

outreach visits (sometimes referred to as academic detailers)

and local opinion leaders.

Educational outreach visits are defined as the use of a

trained person who meets with providers of care in the

practice setting to give information with the intent of

changing the provider’s practice (Oxman 1994). This may

include the use of a range of educational and social marketing

approaches. In contrast, local opinion leaders are individuals

who are viewed by their colleagues as ‘influential’ (either

positively or negatively) in relation to the proposed change

and who are able to exert influence on their colleagues to

change by setting an example, providing education and

creating new norms (Oxman 1994, Locock et al. 2001).

Examples of using both approaches are reported in the

literature on implementing research into practice (Avorn &

Soumerai 1983, Lomas et al. 19915,65,6 , Soumerai et al. 19935,65,6 ,

Davis et al. 1995). Systematic reviews of the effectiveness of

different intervention strategies suggest that educational

outreach visits can be effective, although there is insufficient

evidence to assess the impact of local opinion leaders (Bero

et al. 1998).

The question arises, however, as to how and whether

facilitation is conceptually discrete from the change agent

strategies described as educational outreach and local opinion

leaders. Certainly, elements of the educational outreach visit

approach are evident in some of the facilitation models

studied in the concept analysis, for example, Fullard et al.

(1987) and Cockburn et al. (1992). In their review, Bero

et al. (1998) comment specifically on the lack of a common

approach across different studies to of how particular

interventions are categorized, which makes the process of

reviewing the effectiveness of roles across a number of studies

highly complex.

One distinction between the different roles may be whether

the change agent is working internally or externally to the

environment in which the change is being implemented. For

example, facilitators can be external or internal to the

organization, whereas opinion leaders are often internal

and educational outreach workers (or academic detailers)

tend to be external. There are also other aspects ‘peculiar’ to

a role, for example, academic detailers tend to use marketing

principles, techniques and materials to reinforce their

message, an approach not explicitly acknowledged as part

of a facilitator role. Additionally, some facilitators explicitly

focus on the need to address and develop organizational

systems and culture, whereas this is not a primary concern of

the role of an educational outreach worker, academic detailer

or opinion leader. Overall, however, the distinction between

the facilitator role and that of other change agents, in

particular educational outreach workers, is far from clear.

Effectiveness of facilitator intervention

Just as studies are reported that address the impact of

intervention strategies such as educational outreach visits and

academic detailing, a number of studies also attempt to

evaluate the application of facilitation in health care,

although the majority of these do not focus specifically on

the implementation of evidence into practice. These include

feasibility studies to assess the extension of a particular

facilitation approach, intervention studies to test the effect-

iveness of a facilitation method or role and qualitative studies

to explore the facilitation process and facilitator roles.

Studies also vary as to whether they study patient or practice

outcomes. Again, findings reflect the diverse way in which

facilitation has been conceptualized and applied, making it

difficult to draw meaningful conclusions about the efficacy of

a facilitator intervention.

A number of feasibility studies have been reported which

evaluate the wider applicability of the ‘Oxford Model’, both

to other health care settings and other countries than the

United Kingdom (UK) (Alexander & Harrison 1990, Crotty

et al. 1993, McBride & Moorwood 1994, Schol & Goelen

199677 ). Although each of these studies conclude that the role

of the facilitator was useful, and some that it should be

extended, there is little overlap across the studies in terms of

the specific application of the facilitator role. For example,

facilitation is interpreted in a number of different ways and

the level and intensity of facilitator support varies widely. As

a result, it is not possible to isolate which, if any, dimensions

of the concept are effective in promoting and supporting

change.

Nursing theory and concept development or analysis Getting evidence into practice

Ó 2002 Blackwell Science Ltd, Journal of Advanced Nursing, 37(6), 577–588 583

Table 2 Included studies of effectiveness of facilitator intervention

Study Study method Intervention Results Type of facilitation

Cockburn et al.

(1992) Australia

RCT Short personal presentation

by an educational

facilitator with a

follow-up visit

6 weeks later. Aimed

to improve the use of

a smoking cessation kit

by GP’s

Intervention group were

significantly more likely to

believe that the kit was

less complicated and

reported more knowledge

on how to use it. Yet the

intervention failed to

produce sufficient benefit to

justify the cost

Task focused

External facilitation

Two visits

Education and follow-up

Fullard et al.

(1987) UK

RCT Facilitators introduced

a screening package,

provided training to the

staff, and offered

continuing support and

advice

The intervention group had

significantly more

documented recordings

of blood pressure,

smoking habit and weight

Task focused

External facilitation

Educational visit and

support to set up systems

Ongoing support and

advice

Dietrich et al.

(1992) USA

RCT Physician education and

a facilitator assisted

office system intervention

to improve the early

detection of cancer.

Each practice was

visited three times over

3 months

The office assisted facilitator

groups showed an increase

in a whole range

of screening and advice

giving activities while the

education was only

associated with an increase

in mammography

Task focused

External facilitation

Three visits over 3 months

Support to establish

routines for specific

services

Szczepura et al.

(1994) UK

RCT Three forms of

information feedback:

tabular, graphical

(management awareness

profiles) and graphical

plus an educational

visit from a medical

facilitator

The three forms of feedback

did not differ in

intelligibility

or usefulness but

feedback plus a medical

facilitator was significantly

less acceptable to

practitioners

Task focused

External facilitation

Single visit

Feedback

and discussion

of audit results

Hearnshaw et al.

(1994) UK

Small RCT Facilitated structured

teamwork of primary

health care teams to

enable them to conduct

multidisciplinary audit

The intervention had a

positive effect on the

introduction of effective,

multidisciplinary audit

Mostly task focused using

a structured facilitation

approach; some focus on

team functioning

External facilitation

Repeated visits over a

5-month period

Range of methods, e.g. didactic

presentation, small

group and individual work

Hulscher et al.

(1997) Netherlands

Non randomized

control trial

Intensive outreach visits by

a trained nurse facilitator

to improve the

organization of services

to prevent

cardiovascular disease.

Included offering support,

repeating messages,

involving the practice

team, conducting audits

and providing feedback

Found a significant increase

in the number of practices

in the intervention groups

adhering to established

guidelines

Task and holistic focus

External facilitation

Repeated visits over a period of

time

Multiple methods in use,

including audit and

feedback, education and

teambuilding

G. Harvey et al.

584 Ó 2002 Blackwell Science Ltd, Journal of Advanced Nursing, 37(6), 577–588

A similar picture emerges when studies of the effectiveness

of facilitator intervention are examined (see Table 2).

Again these evaluative studies vary considerably in their

interpretation of facilitation, leading to marked differences

in the intervention and the type of facilitator roles being

evaluated. For example, in the study reported by Hulscher

et al. (1997), facilitation is interpreted as a multifaceted,

intensive approach, with the facilitator using a range of

interventions such as audit and feedback, education,

support, advice and team building. By comparison, in the

study undertaken by Cockburn et al. (1992), facilitation is

largely interpreted as an exercise in education and

persuasion, with the facilitator intervention comprising a

personal presentation and follow-up visit to the general

practitioner to encourage them to make use of smoking

cessation kits. In these two studies, the intensity of the

facilitator intervention varied considerably, ranging from

an average of 25 visits over an 18-month period in the

former to an initial visit lasting an average of 12Æ8 minutes

in the latter.

Other studies have examined the facilitator role using

qualitative research methods often as part of a wider study

(Harvey 1993, Binnie & Titchen 1999, Loftus-Hills &

Harvey 2000). Binnie and Titchen (1999) report on practice

outcomes whereby distinctive facilitator roles and strategies

worked effectively in achieving structural, cultural and

practice changes necessary to create a patient-centred service.

Titchen (2000) research suggests that an external critical

companion enabled nurses to become more patient-centred,

more critical thinkers and to use different types of evidence in

their practice.

In summary, the findings of the evaluative studies suggest

that the presence of a facilitator who provides face-to-face

communication and uses a range of enabling techniques has

some impact on changing clinical and organizational prac-

tice, although the effect size is variable and associated with

differing costs (Loftus-Hills & Harvey 2000). However, it is

difficult to isolate which aspects of the facilitation process or

the facilitator role are more or less effective in influencing

change.

Discussion and conclusions

The body of literature about the role of change agents is

considerable. Despite this, there are few explicit descriptions

or rigorous evaluations of the concept of facilitation. What

exists are multiple perspectives and interpretations and

therefore according to Morse et al.’s criteria the concept is

partially developed but in need of delineation and compar-

ison which necessarily involves more research. Currently this

is difficult because of the various ways facilitation has been

described and studied, often encompassing elements of other

change agent strategies, in particular educational outreach.

Such differences need to be made explicit in study methods

and subsequent reporting.

The working definition of facilitation which has emerged

from this concept analysis builds on that reported in 1998

(Kitson et al. 1998). The analysis reinforces the view that the

facilitator role is about supporting people to change their

practice. It also helps to clarify further some defining

characteristics of facilitation that could help to distinguish

it from other change agent strategies. Namely,

• it is an appointed role as opposed to that of, for example, an opinion leader who through their own personal repu-

tation and influence acts as a change agent;

• this role may be internal or external (or encompass a combined internal/external approach) to the organization

in which the change is being implemented;

• the role is about helping and enabling rather than telling or persuading;

Table 2 (Continued)

Study Study method Intervention Results Type of facilitation

McCormack and

Wright (2000), UK

Before and after

study

Evaluated the impact of

the utilization of an

external facilitator

who worked with the

ward managers and

staff using a range

of approaches including

action plans, support of

an internal

facilitator, action learning

circles and role modelling

The pre/post evaluation

revealed that the ward

had moved from providing

ritualized and routinized

‘poor’ practice to

more patient-centred,

responsive care e.g. action

learning, role (compared to

the control)

Holistic focus

External/internal

facilitator model

Continuous presence over

a prolonged

period of time

Enabling methods in use,

modelling, action planning

The studies in this table have all been subject to critical appraisal and included based on the results of this process.

Nursing theory and concept development or analysis Getting evidence into practice

Ó 2002 Blackwell Science Ltd, Journal of Advanced Nursing, 37(6), 577–588 585

• within the concept of helping/enabling, the focus of facilitation can encompass a broad spectrum, ranging from

the provision of help to achieve a specific task to using

methods which enable individuals and teams to review

their attitudes, habits, skills, ways of thinking and working;

• given the broad focus of the facilitation concept, a wide range of facilitator roles are possible, with corresponding

skills and attributes needed to fulfil the role effectively.

However, questions could still be raised about the extent to

which facilitation is different from strategies such as educa-

tional outreach visits, which also depend on an appointed

role to help and support the change process. One possible

distinction might be that the role and methods employed in

the educational outreach model do not cover as broad a

spectrum of interventions as those described within

the concept of facilitation. Indeed, it could be argued that

the facilitation model described at the left-hand side of the

proposed continua, where facilitation is a task-focused

activity that uses a distinct set of structured methods to

provide support and advice, is conceptually the same as the

educational outreach model.

This in turn may raise questions about whether the entire

proposed continuum represents the concept of facilitation or

whether facilitation as represented by the right-hand side of

the continua presents something conceptually different from

other change agent strategies. In other words, facilitation is

an intervention with a holistic purpose, which employs a

range of enabling roles and skills. Alternatively, it could be

suggested that to function effectively, facilitators need to be

able to move along the whole range of the continua,

depending on the needs of the situation and the change to

be implemented. This implies that effective facilitators need

to be flexible and possess a range of both task-focused and

enabling skills, which are employed according to the needs of

the context or environment in which they are working. In

relation to the conceptual framework (Kitson et al. 1998)

therefore ‘high’ facilitation would be where a specific facili-

tation intervention is employed that is appropriate to the

needs of the particular change situation (see Figure 4).

These are obviously complex issues and the lack of clarity

evident shown by the concept analysis does not allow us to

draw definitive conclusions at this stage. Questions also

remain about how and in what situations change can be

sustained. Clearly the research agenda is large. In relation to

facilitation generally, there is a need to evaluate the effect-

iveness of different models in order to inform our under-

standing of how they impact on getting evidence into

practice. It is still unclear, for example, whether a ‘task,

doing for others’ approach is as effective as a ‘holistic,

enabling’ approach and in what contexts. Given that there is

research to suggest that practitioners do not apply research

findings via a simple deductive process, but need time to

think, translate and particularize research findings (Dawson

1997, Dopson et al. 1999, Titchen 2000), an approach that

enables these to occur may have a greater impact than one

which does not. Equally, however, there is evidence (Deitrich

199488 ) that in certain circumstances, such as in an over-

stretched service, the task orientated, practical approach is

effective. These complexities and issues highlight the import-

ance of and need for further research and will continue to be

explored in the on-going development and testing of the

conceptual framework.

References

Alexander A.M. & Harrison P.I. (1990) A learning facilitator scheme

in community pharmacy practice. The Pharmaceutical Journal

August, 217–219.

Allsop J. (1990) Changing Primary Care: the Role of Facilitators.

King’s Fund, London

Avorn J. & Soumerai S.S. (1983) Improving drug-therapy decisions

through educational outreach. New England Journal of Medicine

308, 1457–1463.

Baker R., Sorrie R., Reddish S., Hearnshaw H. & Robertson N.

(1995) The facilitation of multiprofessional clinical audit in

primary health care teams: from audit to quality assurance. Journal

of Interprofessional Care 9, 237–244.

Barrows H.S. & Tamblyn R.M. (1980) Problem-Based Learning: an

Approach to Medical Education. Springer, New York.

Figure 4 Characteristics of facilitation.

G. Harvey et al.

586 Ó 2002 Blackwell Science Ltd, Journal of Advanced Nursing, 37(6), 577–588

Bero L.A., Grilli R., Grimshaw J.M., Harvey E., Oxman A.D. &

Thomson A.T. (1998) Closing the gap between research and

practice: an overview of systematic reviews of interventions to

promote the implementation of research findings. British Medical

Journal 317, 465–468.

Binnie A. & Titchen A. (1999) Freedom to Practice: the Development

of Patient-Centred Nursing. Butterworth-Heinemann, Oxford.

Carroll E. (1994) Medical audit and the role of the facilitator.

International Journal of Health Care Quality Assurance 7, 8–10.

Cockburn J., Ruth D., Silagy C., Dobbin M., Reid Y., Scollo M. &

Naccarella L. (1992) Randomised trial of three approaches for

marketing smoking cessation programmes to Australian General

Practitioners. British Medical Journal 304, 691–694.

Crotty M., Litt J.C., Ramsay A.T., Jacobs S. & Weller D.P. (1993)

Will facilitators be acceptable in Australian general practice? A

before and after feasibility study. Australian Family Physician 22,

1643–1647.

Davis D.A., Thomson M.A., Oxman A.D. & Haynes R.B. (1995)

Changing physician performance: a systematic review of the effect

of continuing medical education strategies. Journal of the Amer-

ican Medical Association 274, 700–705.

Dawson S. (1997) Inhabiting different worlds: how can research

relate to practice? Quality in Health Care 6, 177–178.

Deitrich A.J. (1994) External support can change primary care

practice patterns. In Disseminating Research/Changing Practice,

Research Methods in Primary Care, Vol. 6 (Dunn E.V. et al. eds),

Sage Publications, London.

Dietrich A.J., O’Connor G.T., Keller A., Carney P.A., Levy D. &

Whaley F.S. (1992) Cancer: improving early detection and preven-

tion. A community practice randomised trial. British Medical

Journal 304, 687–691.

Dopson S., Gabbay J., Locock L. & Chambers D. (1999) Evaluation

of the PACE Programme: final report Oxford Healthcare Manage-

ment Institute. Templeton College University of Oxford & Wessex

Institute for Health Research and Development, University of

Southampton, Southampton.

Ferlie E., Wood M. & Fitzgerald L. (1999) Some limits to evidence-

based medicine: a case study from elective orthopaedics. Quality in

Health Care 8, 99–107.

Fullard E.M. (1994) Facilitating professional change in primary care.

Annals of Community-Oriented Education 7, 73–78.

Fullard E., Fowler G. & Gray M. (1984) Facilitating prevention in

primary care. British Medical Journal 289, 1585–1587.

Fullard E., Fowler G. & Gray M. (1987) Promoting prevention in

primary care: controlled trial of low technology, low cost

approach. British Medical Journal 294, 1080–1082.

Harvey G. (1993) Nursing Quality: An Evaluation of Key Factors in

the Implementation Process. Unpublished PhD Thesis. South Bank

University, London.

Hearnshaw H.M., Baker R.H. & Robertson N. (1994) Multidisci-

plinary audit in primary healthcare teams: facilitation by audit

support staff. Quality in Health Care 3, 164–168.

Heron J. (1977) Dimensions of Facilitator Style. University of Surrey,

Guildford.

Heron J. (1989) The Facilitator’s Handbook. Kogan Page, London.

Hulscher M.E., van Drenth B.B., van der Wouden J.C., Mokkink

H.G., van Weel C. & Grol R.P. (1997) Changing preventive

practice: a controlled trial on the effects of outreach visits to

organise prevention of cardiovascular disease. Quality in Health

Care 6, 19–24.

Jackson A., Ward M., Cutcliffe J., Titchen A. & Cannon B. (1999)

Practice development in mental health nursing: part 2. Mental

Health Practice 2, 2–9.

Johns C. & Butcher K. (1993) Learning through supervision: a case

study of respite care. Journal of Clinical Nursing 2, 89–93.

Johns C. & Kingston S. (1990) Implementing a philosophy of care on

a children’s ward using action research. Nursing Practice 4, 2–9.

Kitson A., Harvey G. & McCormack B. (1998) Enabling the

implementation of evidence-based practice: a conceptual frame-

work. Quality in Health Care 7, 149–158.

Leventhal R.B. (1984) Working hard to make QWL look easy.

Training and Development Journal 38, 59–60.

Locock L., Dopson S., Chambers D. & Gabbay J. (2001) Under-

standing the role of opinion leaders in improving clinical effect-

iveness. Social Science and Medicine 53, 745–757.

Loftus-Hills A. & Harvey G. (2000) A Review of the Role of

Facilitators in Changing Professional Health Care Practice. RCN

Institute, Oxford.

Lomas J., Enkin M., Anderson G.M., Hannah W.J., Vayda E. &

Singer J. (1991) Opinion leaders versus audit and feedback to

implement practice guidelines. Journal of the American Medical

Association 265, 2202–2207.

Marshall J. & McLean A. (1988) In Human Inquiry in Action.

Developments in New Paradigm Research. (Reason P. ed.), Sage,

London, pp. 00–00.

McBride A. & Moorwood Z. (1994) The hospital health-promo-

tion facilitator: an evaluation. Journal of Clinical Nursing 3,

355–359.

McCormack B. & Garbett R. (2001) A Concept Analysis of Practice

Development. RCN Institute, Oxford.

McCormack B., Manley K., Kitson A., Titchen A. & Harvey G.

(1999) Towards practice development: a vision in reality or a

reality without vision? Journal of Nursing Management 7,

255–264.

McCormack B. & Wright J. (2000) Achieving dignified care for older

people through practice development – a systematic approach. NT

Research 4, 340–352.

McKenna H. (1997) Nursing Theories and Models. Routledge,

London.

Moore C.H. & Kovach K.M. (1988) Task force: a management

techniques that produces quality decisions and employee commit-

ment. Journal of the American Dietetic Association 88, 52–55.

Morrell C. & Harvey G. (1999) Clinical Audit Handbook. Ballière-

Tindall, London.

Morrell C., Harvey G. & Kitson A. (1995) The Reality of Practi-

tioner Based Quality Improvement – A Review of the Use of the

Dynamic Standard Setting System in the NHS of the 1990s. Report

no. 14. National Institute for Nursing, Oxford.

Morse J.M. (1995) Exploring the theoretical basis of nursing using

advanced techniques of concept analysis. Advances in Nursing

Science 17, 31–46.

Morse J.M., Hupcey J.E., Mitcham C. & Lenz E.R. (1996) Concept

analysis in nursing research: a critical appraisal. Scholarly Inquiry

for Nursing Practice: An International Journal 10, 253–277.

Oxford English Dictionary (1989) 2nd edn, Vol. V. Clarendon Press,

Oxford.

Nursing theory and concept development or analysis Getting evidence into practice

Ó 2002 Blackwell Science Ltd, Journal of Advanced Nursing, 37(6), 577–588 587

Oxman A. (1994) No Magic Bullets: A Systematic Review of 102

Trials of Interventions to Help Health Care Professionals Deliver

Services More Effectively and Efficiently. North East Thames

Regional Health Authority, London.

Paley J. (1996) How not to justify concepts in nursing. Journal of

Advanced Nursing 24, 572–578.

Palmer A., Burns S. & Bulman C. (1994) Reflective Practice in Nursing:

the Growth of the Professional Practitioner. Blackwell, Oxford.

Reason P. (ed.) (1988) Human Inquiry in Action. Developments in

New Paradigm Research. Sage, London.

Reason P. & Rowan J. (1981) Human Inquiry: a Sourcebook of New

Paradigm Research. Wiley, Chichester.

Rogers C.R. (1951) Student-Centred Teaching. Client Centred

Therapy: its Current Practice, Implications and Theory. Constable,

London.

Rogers C.R. (1969) Freedom to Learn. Merrill, Columbus.

Rogers C.R. (1983) Freedom to Learn for the 80s. Merrill, London.110

Rogers B.L. (1994) Concepts, analysis and the development of

nursing knowledge: the evolutionary cycle. In Models, Theories

and Concepts (Smith J. ed.), Blackwell Science, Oxford, pp. 21–30.

Royal College of Nursing (1990) Quality Patient Care: The Dynamic

Standard Setting System. Scutari, London.

Schol S. & Goelen G. (1996) Facilitating general practitioners

in Belgium. European Journal of General Practice December,

170–171.

Smith G.B. & Hukill E. (1994) Quality work improvement groups:

from paper to reality. Journal of Nursing Care Quality 8, 1–12.

Soumerai S.B., Salem-Schatz S., Avorn J., Casteris C.S., Ross-Degnan

D. & Popovsky M.A. (1993) A controlled trial of educational

outreach to improve blood transfusion practice. Journal of the

American Medical Association 270, 961–966.

Szczepura A., Wilmot J., Davies C. & Fletcher J. (1994) Effect-

iveness and cost of different strategies for information feedback

in general practice. British Journal of General Practice 44,

19–24.

Thompson C., McCaughan D., Cullum N., Sheldon T.A., Mulhall A.

& Thompson D.R. (2001a) The accessibility of research-based

knowledge for nurses in United Kingdom acute care settings.

Journal of Advanced Nursing 36, 11–22.

Thompson C., McCaughan D., Cullum N., Sheldon T.A., Mulhall A.

& Thompson D.R. (2001b) Research information in nurses’

clinical decision-making: what is useful? Journal of Advanced

Nursing 36, 376–388.

Titchen A. (1987) The design and implementation of a problem-

based, continuing education programme: a guide for clinical

physiotherapists. Physiotherapy 73, 318–323.

Titchen A. (2000) Professional Craft Knowledge in Patient-Centred

Nursing and the Facilitation of its Development. University of

Oxford DPhil Thesis. Ashdale Press, Kidlington.

Walker L.O. & Avant C.K. (1995) Concept analysis. In Strategies for

Theory Construction in Nursing, 3rd edn, Appleton & Lange,

Norwalk, Connecticut, pp. 37–54.

Ward M., Titchen A., Morrell C., McCormack B. & Kitson A.

(1998) Using a supervisory framework to support and evaluate a

multi-project practice development programme. Journal of Clinical

Nursing 7, 29–36.

G. Harvey et al.

588 Ó 2002 Blackwell Science Ltd, Journal of Advanced Nursing, 37(6), 577–588