Enhancing Care for Older People - Health Service Executive

Enhancing Care for
Older People
A Guide to Practice Development
Processes to Support and Enhance Care
in Residential Settings for Older People
June 2010

Enhancing Care for
Older People
A Guide to Practice Development
Processes to Support and Enhance Care
in Residential Settings for Older People
June 2010

Health Service Executive
© Enhancing Care for Older People - A Guide to Practice Development Processes to Support
and Enhance Care in Residential Settings for Older People
June 2010
ISBN: 978-1-906218-35-5

Table of Contents
Foreword 04
Acknowledgements 06
Section 1 Background 07
1.1 Introduction 07
1.2 Strategic context in the Republic of Ireland 07
1.3 Person-centred philosophy 08
1.4 Older Person Service National Practice Development Programme 2007-2009 08
1.5 Objectives of the programme 08
1.6 Outcomes of the National Programme 10
1.7 Governance framework for the National Programme 10
Section 2 Person-centred Care and Practice Development 11
2.1 Introduction 11
2.2 Person-centred care 11
2.3 Person-centred Nursing Framework 11
2.4 Practice Development 13
2.5 Practice Development approaches 14
2.6 Emancipatory Practice Development 14
2.7 Health Service Executive (HSE) Change Model and Practice Development 16
Section 3 Facilitating Change and Enhancing Practice 19
3.1 Introduction 19
3.2 Facilitation and Practice Development 19
3.3 Facilitating the Practice Development journey 20
3.4 Reflective practice 21
3.5 High Challenge/High Support (HC/HS) 25
3.6 Example of an activity to introduce the process of High Challenge/High Support 27
3.7 Giving and receiving feedback 28

Section 4 Changing the Culture and Context of Care – Collecting the Evidence 29
4.1 Introduction 29
4.2 Commencing the process or the programme 29
4.3 Establishing the PD group – the steps 30
4.4 Terms of engagement (ground rules or contract) 31
4.5 Values clarification work – sharing and creating a vision for practice 32
4.6 Observations of care 32
4.7 Environmental observation 33
4.8 Person-centred language exercise 35
4.9 Resident narratives/stories 36
4.10 Quality of life exercise – “Cats, skirts and lipstick” 37
4.11 Life story work 38
Section 5 Evaluating Change and Enhancing Practice 39
5.1 Introduction 39
5.2 What is evaluation in Practice Development? 39
5.3 Developing an evaluation strategy 40
5.4 Claims, Concerns and Issues (CCIs) 41
5.5 Problem solving framework 42
5.6 Importance of celebration and sharing praise in Practice Development work 43
Section 6 Conclusion 44
References 45
Bibliography 49

Appendices
Appendix 1 The National Programme Team and Participating Sites 52
Appendix 2 Feedback Guidance 55
Appendix 3 Example of an Agenda for PD Workshop and Meeting Notes Template 59
Appendix 4 Values Clarification Exercise 62
Appendix 5 Observation of Care Information 66
Appendix 6 Workplace Culture Critical Analysis Tool 72
Appendix 7 Resident Narrative/Interview Guide Questions 92
Appendix 8 Quality of Life Exercise – ‘My day, my way’ 93
Appendix 9 Action Planning Framework 95
Appendix 10 Facilitator Guidance for Claims, Concerns and Issues (CCIs) Exercise 102
List of Figures
Figure 1.1 Facilitation Framework 09
Figure 2.1 The Person-centred Constructs 12
Figure 2.2 Person Centred Nursing Framework 13
Figure 2.3 HSE Change Model 17
Figure 2.4 Key Leadership Attributes Required to Implement
Change and Enhance Practice 18
Figure 3.1 Skills Associated with Reflection 22
Figure 3.2 Gibbs Reflective Cycle 23
Figure 3.3 High Challenge/High Support Grid 26
Figure 4.1 Example of Terms of Engagement for a PD group 31

Foreword
It is with great pleasure that I introduce ‘A Guide to Practice Development Processes to Support
and Enhance Care in Residential Settings for Older People’. The purpose of this guide is to
provide a practical support for healthcare teams working in older person services. It aims to
assist in developing and sustaining a person-centred approach using practice development
processes.
The evidence based practice development tools and processes outlined in this guide
have been utilised and tested while delivering the Older Person Service National Practice
Development Programme 2007-2009, across multiple settings in Ireland. This was a
collaborative action research project involving the University of Ulster and the Health Service
Executive. This programme is now complete and the final report is available on request.
Following on from the project, the National Programme Team produced this guide in
order to further enable and sustain the development and enhancement of person-centred
cultures across our older person sites in Ireland.
An important outcome from the programme was the development of a cadre of expertise
in person-centred practice development. Many of these practitioners are working in the
older person residential services delivering care using emancipatory practice development
principles.
A key policy driver for the development of this guide was the recent introduction of the
National Quality Standards for Residential Care Settings for Older People in Ireland (Health
Information and Quality Authority, (HIQA) 2009). One of the principles informing the
Authority’s approach to the development of standards for older person services is personcentredness.
I wish to thank the Directors of Nursing and Midwifery Planning and Development Units
(NMPDU), Directors of Nursing and their teams from the 17 participating sites for their
commitment to the programme.
As this guide is the product of a collaborative process, I would like to acknowledge Professor
Brendan McCormack, Professor Jan Dewing and the lead NMPDU facilitators for their input
and expertise in the development of this resource.
Finally, I wish to acknowledge and thank Liz Breslin, North West NMPDU and Mary Manning,
Midland NMPDU for all their work in bringing this guide to completion.
Patrick Glackin
Acting Area Director Nursing and Midwifery Planning and Development
Health Service Executive West
Republic of Ireland
4

Foreword
If you are interested in enhancing the well being and quality of life of older people or
striving to be a more effective leader in your healthcare workplace then this resource will be
particularly useful for you.
This guide has been developed following a two year national practice development
programme across the Republic of Ireland. The Older Person Service National Practice
Development Programme 2007-2009 involved older people, families and multidisciplinary
staff (including, for example: registered nurses; care support workers; catering; domestic;
gardening; maintenance; administration and medical staff) in 17 older person service
residential sites across the four Health Service Executive [HSE] Administrative Areas in
the Republic of Ireland. This was a collaborative programme between the University of
Ulster and six Nursing and Midwifery Planning and Development Units (NMPDU). It was
funded by the National Council for the Professional Development of Nursing and Midwifery
and NMPDUs. In the residential care sector newly developed ‘National Quality Standards
for Residential Care Settings for Older People in Ireland’ (Health Information and Quality
Authority, 2009) have been introduced. These have person-centred practice as a central
strategic direction of service delivery. Therefore, this person-centred practice development
programme was consistent with the health services’ national priorities and the commitment
to development of quality services that are evidence-informed and person-centred.
No matter what the intent of developing quality services that are person-centred and
evidence-informed, it is clear that teams need tools and resources to be made available to
help work towards these cultures. This resource will help you make use of key aspects of the
practice development methodology and processes, to be more effective in how you design
and enhance care and service delivery for older people in residential care, whether in the
HSE or private sector. The activities in this resource should also show that enhancing care
can be interesting and fun for staff.
At this point, we acknowledge all the staff, residents and families who were part of the
national programme and have in some way contributed to this resource being developed.
Additionally, the programme team members who embraced the ideas, tools and methods
offered to them and embraced these different and sometimes challenging ways of working.
This programme has made a big difference to the work of those involved and most
importantly to the wellbeing of older people. This resource is our way of offering you a taste
of that programme in the hope that it will enable you and colleagues to move forward with
your own development work in a creative and systematic way.
Professor Brendan McCormack
Professor of Nursing Research/Head of the
Person-centred Practice Research Centre and
Director of the Institute of Nursing Research,
University of Ulster, Northern Ireland.
Professor Jan Dewing
Head of Person-centred Research and Practice Development/
Professor East Sussex Community Health NHS/Canterbury
Christchurch University, Kent, England.
Honorary Research Fellow, University of Ulster, Northern Ireland
Visiting Professor of Aged Care and Practice Development
SNMIH/University of Wollongong, NSW Australia.
5

Acknowledgements
We would like to take this opportunity to recognise that the practice development (PD)
processes and tools outlined in this document have been developed and/or adapted
from international/national work and have been referenced accordingly throughout the
document. We would also like to express sincere appreciation to the authors of these
processes who constantly endeavour to promote this methodology by sharing and
publishing their work. The PD processes and tools outlined were utilised in the Health Service
Executive (HSE) Older Person Service National Practice Development Programme 2007-2009 in
17 residential sites in Ireland. By adopting this approach to supporting and enhancing care,
we can as PD facilitators, influence the way healthcare teams work and ultimately have a
positive impact on care delivery.
Special acknowledgement is due to the National Council for Professional Development of
Nursing and Midwifery for providing the funding for this programme over the two years. Also,
particular thanks to the Directors of the Nursing and Midwifery Planning and Development
Units for their ongoing support and encouragement.
Finally, sincere thanks to all of the residents, patients, families, healthcare teams and key
individuals who were significant stakeholders in the Older Person Service National Practice
Development Programme 2007-2009.
Elizabeth Breslin and Mary Manning
on behalf of the National Programme Team
6

Section 1
Background
1.1 Introduction
The purpose of this guide is to provide a practical support to assist healthcare teams
working in older person services to continue to develop and sustain person-centred practice
using Practice Development (PD) processes. The guide has six sections, beginning with an
introduction to the strategic context and an overview of the Older Person Service National
Practice Development Programme 2007-2009. Section two explores the concept of personcentred
care and PD as a model of delivery. Section three discusses facilitation skills which
are integral to promoting change and enhancing practice through PD. In section four,
information is provided on how to collect evidence from practice using evidence based PD
tools and processes. In section five, the process is continued with an overview of action
planning and evaluation phases. These are reliant on utilising and developing facilitation
skills and PD methodologies. Section six concludes the guide. Throughout this document,
links to appendices are provided. It is important that this guide should only be seen as an
extension and support to healthcare teams drawing on the three key processes within PD.
These are
Collaboration Inclusion Participation
Further reading and reflection is recommended for the healthcare team on the PD journey.
1.2 Strategic context in the Republic of Ireland
As healthcare providers we are focused on the care that older people receive and the
context in which care is provided. Drivers for implementing a person-centred approach for
older people have been prompted by many different factors which include the humanistic
imperative; changing demographics; national and international evidence; as well as the
increasingly high public profile of older people in our communities. The most recent policy
influences are the health strategy, Quality and Fairness - A Health System for You (DoH&C,
2001), public investigations such as the Leas Cross Nursing Home Review (O’Neill, 2006),
and the National Quality Standards for Residential Care Settings for Older People in Ireland
(Health Information and Quality Authority (HIQA), 2009).
7

1.3 Person-centred philosophy
Taking cognisance of the need to provide a person-centred philosophy requires healthcare
teams to be innovative, creative and to continually strive towards achieving this approach.
The PD ethos advocates collaborative team working to enable the implementation and
sustainability of a culture of person-centred care in residential healthcare settings for older
people. PD strategies aim to generate motivation and enthusiasm in teams. These can
be achieved by building on the existing knowledge and experience within the team and
creating a vision for the service which is inclusive of the service users and service providers.
1.4 Older Person Service National Practice
Development Programme 2007-2009
This was a collaborative research programme between the HSE and the University of Ulster,
involving healthcare teams and residents from 17 residential units in the Republic of Ireland.
The aim of the programme was ‘to implement a framework of person-centred nursing for
older people across multiple settings in Ireland, through a collaborative facilitation model and
an evaluation of the processes and outcomes’. The model of PD used places importance on
working with a shared vision based on collective values and beliefs.
1.5 Objectives of the programme
In order to coordinate a programme of work that can replicate effective PD processes in care
settings for older people, the programme had the following objectives.
• Enable participants/local facilitators and their Directors of Nursing and managers to
recognise the attributes of person-centred cultures for older people and key PD and
management interventions needed to achieve the culture, therefore, embedding
person-centred care within organisations.
• Develop a person-centred culture in participating practice settings.
• Measure systematically or evaluate outcomes of practice for older people.
• Further test a model of person-centred practice in residential care and develop this as
a multi-professional model.
• Use a participant generated data-set to inform the development and outcomes of
person-centred practice.
• Enable NMPDU facilitators to work with shared principles, models, methods and
processes in PD work across services for older people.
A facilitation team was established and consisted of two practice development researchers
from the University of Ulster and six nurses from the Nursing and Midwifery Planning and
Development Units (NMPDU) who worked as facilitators in each of the residential units in
their geographical areas. Each of the 17 participating units in the programme established
8

a multidisciplinary PD group. The group members were known as programme participants
and within each of these groups, nurses holding grades from Director of Nursing (DON)
to staff nurse were identified as internal facilitators. The facilitation framework for the
programme is illustrated in Figure 1.1 and the national programme team and participating
sites are outlined in Appendix 1.
Figure 1.1: Facilitation Framework
University of
Ulster Practice
Development
Researchers
NMPDU nurse
facilitators
Internal
facilitators from
the residential
units
A structured programme of work was implemented in each of the residential sites over
the two year period, with facilitated programme/workshop days taking place every four to
six weeks. A wide collection of evaluation processes or tools were used in the programme
including quantitative and qualitative approaches. These are detailed as follows:
• Reflective process accounts
• Context Assessment Index [CAI] (McCormack et al., 2006)
• Person-centred Nursing Index [PCNI] (Slater and McCormack, 2006)
• Person-centred Caring Index (PCCI) (Slater and McCormack, 2006a)
• Cultural Observation Tool [Workplace Culture Critical Analysis Tool – WCCAT]
(McCormack, Henderson, Wilson and Wright, 2007)
• Resident Narratives (Hsu and McCormack, 2006)
• Interviews with key stakeholders
Multidisciplinary
PD groups
The processes used and subsequent outcomes were evaluated within a framework of
cooperative inquiry, primarily drawing upon reflective dialogue data between the nurse
facilitators and the healthcare teams in the participating sites. The programme was
completed in September 2009; a final report will provide further detailed information
(McCormack et al., 2010). An overview of the outcomes of the national programme and the
governance framework is outlined on page 10.
9

1.6 Outcomes of the National Programme
• There is evidence to support the effectiveness of using the PD approach and the person
10
centred practice model to positively enhance care for older people.
• Multidisciplinary healthcare teams recognised the attributes of person-centred
cultures for older people as well as the key PD and management interventions needed
to achieve a change in the culture and context in which care is provided.
• The development and enhancement of person-centred cultures in participating
practice settings.
• NMPDU facilitators, internal facilitators, the PD groups and the wider healthcare team
were enabled to work with shared principles, models, methods and processes in PD
work across older person services.
• The processes used in the programme were clearly mapped to the National Quality
Standards for Residential Care Settings for Older People in Ireland (HIQA 2009).
1.7 Governance framework for the National
Programme
The programme had a structured governance framework and consisted of the following
phases.
1 There was an ethical protocol established for the programme and approval
granted from local ethical committees (McCormack and Dewing, 2007).
2 The establishment of a strategic steering group consisting of Directors of
NMPDU and programme leaders.
3 A reporting system between the NMPDU directors and NMPDU facilitators
in relation to the progress of the programme, including the challenges and
opportunities it presented was established. Programme evaluation reports were
produced by the national team.
4 The establishment of monthly meetings/workshops for the national programme
team over the two year period. This involved reviewing progress, learning,
identifying challenges/achievements, action planning, evaluation and any other
issues in relation to the programme. This was then cascaded down by NMPDU
facilitators locally to internal facilitators and to the PD groups in each of the
individual sites.
5 The establishment of a DON group as well as a national reference group.

Section 2
Person-Centred Care and
Practice Development
2.1 Introduction
A person-centred philosophy is central to healthcare both in the context of the provision of care
to residents and also to enable healthcare teams to function in an effective way. This section is
intended to provide a foundation in relation to the theoretical components of person-centred care
and PD.
2.2 Person-centred care
Person-centred care is focused on respecting and valuing each person as a unique individual with
rights. This involves engaging with others in a way that promotes their dignity, sense of worth
and independence. A person-centred approach is fundamental and core to healthcare teams and
in turn promotes independence and autonomy for residents and their families/carers. This caring
approach enables healthcare teams to be flexible and innovative and is achieved by working with
a collaborative team philosophy (Innes et al., 2006). The following definition of person-centredness
was established by the facilitation team working on the national PD programme.
“ Person-centredness is an approach to practice established through the
formation and fostering of therapeutic relationships between all care providers,
older people and others significant to them in their lives. It is underpinned by
values of respect for persons, individual right to self determination, mutual
respect and understanding. It is enabled by cultures of empowerment that foster
continuous approaches to practice development ”
2.3 Person-Centred Nursing Framework
(McCormack et al, 2010a)
McCormack and McCance (2006; 2010) clarify how a person-centred philosophy can be adopted
by presenting an evidence based theoretical framework which can be used as a methodology to
enable person-centred care become a reality. The framework proposed was used on the national
person-centred care programme. It is relevant in all healthcare settings and incorporates four
constructs which are inter-dependent; these are now described and illustrated in Figure 2.1 and
Figure 2.2.
11

Figure 2.1: The Person Centred Constructs (McCormack and McCance 2006; 2010)
12
1 Attributes of the carer
– prerequisites of the
individual member of the
healthcare team
2 Context in which care
is delivered – the care
environment
3 Delivery of care through
a range of activities – care
processes
4 Results of effective personcentred
care/person -
centred outcomes
• Professionally competent
• Effective interpersonal skills
• Commitment to the job
• Clarity of beliefs and values
• Appropriate skill mix
• Systems that facilitate shared
decision making
• Effective staff relationships
• Supportive organisational systems
• Sharing of power
• Potential for innovation and risk
taking
• Working with patients’ beliefs and
values
• Engagement
• Sympathetic presence
• Sharing decision making
• Providing for holistic care
• Satisfaction with care
• Involvement with care
• Feeling of well-being
• Creating a therapeutic culture
This framework (Figure 2.1 and Figure 2.2) suggests that if healthcare teams and
organisations systematically attend to the care environment and the attributes of the care
giver, it enables care givers to work with older people in authentic ways. A philosophy of
person-centred care will gradually be realised and person-centred care outcomes achieved.
This framework when utilised with a PD approach provides a method for effective change in
the culture and context of care. The core principles of this approach fit with the vision of the
health services in Ireland.

lues • Knowing ‘Self’
Figure 2.2: Person Centred Nursing Framework
Providing
Holistic
Care
2.4 Practice Development
Working with
the Patient’s Beliefs
and Values
Person Centred
outComes
• Satisfaction with Care
• Involvement with Care
• Feeling of Well-being
• Creating a Therapeutic
Culture
Engagement
Professionally Competent • Developed Interpersonal Skills • Commitment to the Job • Clarity of Beliefs and Va
Having
Sympathetic
Presence
Appropiate Skill Mix • Shared Decision Making Systems • Eff
Prerequisites
Care ProCesses
ective Staff Relationships • Supportive Organisational Systems • Po
Shared Decision
Making
the Care environment
(McCormack and McCance, 2006; 2010)
Practice development (PD) is an organised approach to changing and improving practice
through the systematic transformation of care practices and culture. Change management
at any level in healthcare organisations is not easy. There are a range of influencing factors
requiring a systematic and planned approach to implementing change. Clinical practice
environments are continuously experiencing change due to different drivers such as policy,
quality issues/initiatives, resources, staffing and changing individual needs. PD is a term
used to describe a variety of methods for developing and changing healthcare practice,
particularly in the context of clinical care (McSherry and Warr, 2008; Manley et al., 2008).
wer Sharing • Potential for Innovation
and Risk Taking • The Physical Environment
13

There tends to be two approaches, technical and emancipatory (Manley and McCormack
2004), with the emergence of a transformational approach (Titchen and McCormack 2008).
2.5 Practice Development approaches
The purpose of PD is to implement change in practice, ultimately influencing the individual’s
experience of healthcare and enhancing healthcare team effectiveness. The approaches
used, technical PD and emancipatory PD have different methodologies. Technical practice
development (tPD) consists of a range of activities that tend to focus on the development of
a specific aspect of practice (Dewing 2008). These are usually short term and can be separate
initiatives. In tPD, the objective is usually known and the focus is on achieving the outcome
rather than being concerned with the means of achieving it (Manley and McCormack, 2004).
The approach is usually task based and project specific, such as putting a new policy into
practice or learning new technical skills. These skills or new ways of working can sometimes
be learned in a classroom or laboratory setting and applied in practice, subject to developing
competencies and skills. This type of approach is considered useful when implementing
change but may not be an appropriate or an effective approach where there are issues
relating to achieving sustainable change in the culture of care. Kitson et al., (1996) refers to
this method as a ‘top down’ approach to implementing change; one that is concerned with
traditional change management approaches in a contemporary health care setting.
2.6 Emancipatory Practice Development
Emancipatory practice development (ePD) is a change methodology that is concerned with
improving practice through the development and sustainability of person-centred cultures.
The focus of ePD is on developing sustainable effective workplace cultures to enable
change to occur within the ethos of person-centredness (McCormack et al., 2008). A similar
viewpoint is put forward by McMahon and O’Carroll (2000) who refer to this approach as
promoting the development of skills and knowledge of nurses and other members of the
healthcare team, while working towards a person-centred ethos. Chin and Hamer (2006)
propose that ePD is widely recognised as a mechanism to reflect upon everyday practice
issues to implement ‘bottom up’ change in healthcare organisations which is in direct
contrast to a ‘top down’ approach.
Manley and McCormack (2004) believe that ePD is primarily aimed at affecting and sustaining
change that will improve patient care. The focus is on transforming the context and culture of
the care environment by employing a systematic evidenced based approach. Processes such
as values clarification work, observations of care, patient narratives and reflective practice
are integral to ePD. This is a continuous process and can be facilitated either internally in the
organisation or by external facilitators. Skilled facilitation in relation to teams is critical to
the successful implementation of change using ePD. The role of facilitation has significant
value in healthcare environments. It supports multidisciplinary teams and also meets the
challenges of providing continuous quality improvements for patients. This is very relevant in
the Republic of Ireland where effectiveness, efficiency and continuous quality improvement
14

are strategic objectives in the provision of healthcare across all services. There is evidence to
support the use of ePD as an approach in the Irish context and also internationally. One of
the prerequisites of this approach is the identification and involvement of key stakeholders.
In the context of using this approach in settings where older people are the primary service
user, the involvement of the multidisciplinary team and older people is crucial. The following
is a definition of PD used on the national PD programme which provided a reference and
foundation for all of the participants on the programme.
Practice development is a continuous process of developing
person-centred cultures. It is enabled by facilitators who authentically
engage with individuals and teams to blend personal qualities and
creative imagination with practice skills and practice wisdom.
The learning that occurs brings about transformations of individual and
team practices. This is sustained by embedding both processes and
outcomes in corporate strategy.
(Manley et al., 2008, p. 9)
For PD to be effective as an approach to implementing and sustaining cultural change,
working collectively as a team is crucial. The pace and scope of change expected in the
health service requires healthcare teams to be flexible and responsive in order to adapt to
change (HSE, 2008).
Effective PD requires the adoption of three key principles – collaboration, inclusion and
participation (CIP), along with active learning (Dewing 2008; 2009) and skilled facilitation.
PD provides a systematic approach to developing person-centred systems and patterns of
work where everyone is involved in changing the culture from task focused care to personcentred
care. In order to understand how care practices are arranged, it may be appropriate
to assess the current model of care in organisations. Ask yourself this question – is the care
in your unit/hospital task orientated? Task focused care is about staff getting their work done
and the residents fitting into a pre-existing routine. Person-centred care is about working
together with residents on the things that are important to them without the restraint of
rituals and routines.
Practice Development involves:
• Skilled facilitation.
• Use of existing evidence/developing new insights/developing local evidence.
• Team ownership and involvement.
• Improvement of relationships with patients/clients and healthcare teams.
• Exploration of views while recognising the interests of all those involved.
15

• Challenging assumptions, taken for granted accepted norms and rituals.
• Developing a culture which is receptive to change through systematic approaches.
• Developing and supporting staff to engage in critical debate and to reflect on
practice.
• Valuing and building on existing knowledge and skill(s) and sharing these amongst
healthcare teams.
• Changing practice to reflect new or articulated values and beliefs.
• Providing support and supervision to staff in the change process.
• Ensuring that changing and enhancing practice is a cyclical process.
• Formal evaluation using evidence based processes.
• A commitment to openness and honesty within teams in order to foster a climate in
which all staff actively and equally engage in developing practice.
16
ROYAL COLLEGE OF NURSING, 2007 (ADAPTED)
2.7 Health Service Executive (HSE) Change Model
and Practice Development
In order to explore and understand the purpose of utilising PD as a change model, it is
necessary to discuss the concept of change management in a wider context with specific
emphasis on the approach that is advocated in the Irish Health Service. Implementing
change in any context is not straight forward. From the outset, it is essential to recognise
that change must be approached as a continuous process in which all of the elements
are interrelated and can influence each other. In the context of residential settings, this
includes the resident, healthcare team and the wider organisation. Organisational change
comes about through staff transforming the way duties are carried out, clarity around role
definition being provided, and the healthcare team being enabled to explore the culture and
context of the care environment. Any type of change takes time and requires a framework/
methodology. It is important for a successful outcome to have an appropriate framework so
that change is planned and managed in a structured way. Combining this methodology with
a focus on the people dynamics of change is an essential element of the HSE Change Model
(HSE, 2008). These elements are also integral to the PD model where the aim is quality and
service improvement using person-centred approaches. Figure 2.3 provides an overview of
the HSE Change Model.

Figure 2.3: HSE Change Model (HSE, 2008)
INITIATION
1. Preparing to
Lead the Change
7. Evaluating
and Learning
MAINSTREAMING
6. Making it
“the way we do our
business”
2. Building
commitment
Change model adapted from:
Kolb, D. and Frohman, A. (1970), Huse, E. (1980), Neumann, J. (1989), Kotter, J.P. (1995)
and Ackerman Anderson, L. and Anderson, D. (2001).
The implementation of change through the use of PD is a systematic and structured
approach to move from one situation to another, in order to change the culture and context
of care provision. The processes and structures used in PD are similar to the HSE Change
Model as identified in Improving Our Services: a Users’ Guide to Managing Change in the
Health Service Executive (HSE, 2008).
The approach referred to in PD and the HSE 2008 model promotes a collaborative and
supportive approach and involves:
• Paying particular attention to the people involved and cultural aspects of change.
• Involving service users in all aspects of the process.
PLANNING
3. Determining
the Detail of the
Change
4. Developing
the Implementation
Plan
IMPLEMENTATION
5. Implementing
Change
• Focusing on the connections, relationships and dependencies between different parts
of the system.
• Prioritising long-term sustainable change and improved organisational effectiveness.
• Paying attention to the transfer of knowledge and skills so that the system equips itself
to manage change in the future.
• Supporting the values of participation and development and placing a strong emphasis
on human resource practices and team work.
• Promoting processes of regular feedback and evaluation at all stages of the change
journey.
17

Practice Development processes and the HSE change model recognises
that:
• There needs to be support from local senior management and the wider management
circle in the appropriate health service or specific unit.
• A healthcare team needs to be established to lead and drive the change. This team
needs to have representatives from all key and appropriate areas.
• Identification of a named person to facilitate and guide the healthcare team through
the PD processes; ideally this person needs to have commitment and authority to
ensure that staff are supported through the change process.
• Leadership is integral to the process.
Figure 2.4: Key Leadership Attributes Required to Implement Change and Enhance
Practice
Adapted from: Kotter, J.P (1995), Ackerman Anderson L. and Anderson D. (2001), Coghlan D. and
McAuliffe (2003), NHS Institute for Innovation and Improvement (2005), McAuliffe and Can Vaerenbergh
(2006), and Moss Kanter, R. (2001) (HSE, 2008)
It is critical to identify key leadership attributes; the acknowledgement of these qualities
within the healthcare team is an important part of the PD journey, as illustrated in Figure
2.4. This also forms part of the learning that facilitators and participants discover about
their own abilities on the PD journey through active learning and creative activities.
18
Support
continious
learning and
evaluation
Balance stability
and change
Establish a sense
of urgency and
pace the change
Create a
shared vision
Attend to the
people and
cultural aspects of
change
Lead by
examPLe
Focus on
service users,
communities and
population
Support effective
team working
Engage key
stakeholders
Resource
the change
Communicate
relentlessly

Section 3
Facilitating Change and
Enhancing Practice
3.1 Introduction
In order to implement change there needs to be a process which will support and enable
the change. It is accepted that facilitation is essential to this process and is inextricably
linked to practice development and person-centred care. Facilitation is a key component
when implementing change and enhancing practice. This section is intended to provide an
overview of the facilitation skills which are integral to the process.
3.2 Facilitation and Practice Development
Facilitation is a skill that can be developed over a period of time and requires learning,
taking risks and getting to know yourself. Clarke et al., (2008) discuss how facilitation is less
preoccupied with outcomes and more concerned with enabling and empowering others.
Facilitation is unique to each individual. It is not about achieving short-term gains, but is
more concentrated on ensuring that individuals have the appropriate experiences, skills
and knowledge to enable others to assume responsibility, and take the lead to bring about
change which is sustainable. Roycroft-Malone et al (2002) refer to facilitators as having a
key role to play in helping individuals and teams to understand what they need to change
and how they need to change in order to apply evidence to practice. Harvey et al (2002)
describes facilitation as a method by which one person makes things easier for others.
The facilitator in PD acts as a guide and support system, but this does not mean he/she directs
or controls everything. The facilitator works collaboratively with individuals/small groups
to assist them to achieve agreed goals in the most effective way. There are many different
approaches to facilitation including prepared activities, opening exercises, connections and
engagement, smoothing the content and processes of the meeting or workshop, closing,
following up with action planning, critical reflection and evaluation.
The following key points are central to facilitating change:
• Understanding why working with values and beliefs is an important foundation.
• Having clarity of purpose for each individual.
• Working with context and workplace culture - for example, facilitating a team/unit
meeting or a change in work practice.
19

• Knowing the other person(s) role in the team and finding the best way to enable
20
other(s) to be creative and active.
• The development of active learning methodologies.
(Royal College of Nursing, 2007)
The role of the facilitator involves the following key responsibilities:
• Assist the healthcare team to define its overall goal and objectives through, for
example, values clarification exercises, terms of engagement, reflecting on practice.
• Assist the PD group to establish its terms of engagement/ground rules.
• Guide individuals to assess their needs and develop plans to achieve their goals.
• Provide processes that help individuals use their time efficiently and effectively to
make decisions.
• Guide the PD group to stay focused on their objectives.
• Maintain accurate records to reflect the ideas of the PD group.
• Assist the PD group in understanding its own processes in order to work more
effectively.
• Use consensus to help the group/individuals make decisions that are reflective of the
group.
• Provide feedback to the group in order for them to evaluate their own progress.
• Manage conflict using a collaborative approach.
• Help the PD group communicate and access resources effectively.
• Create a positive/safe environment in which individuals/PD groups can work
productively.
• Foster leadership in others by sharing the responsibility of leading the process.
• Empower and nurture personal development and human flourishing.
(Adapted from Bens, 2005)
3.3 Facilitating the Practice Development journey
To become an effective leader of change through utilising PD as a methodology, the
development of facilitation skills is integral to the process. This section explores the skills
necessary for the team to undertake this journey as a facilitator of change; it is important
to remember that as time progresses the team will continually learn new skills as well as
identify personal growth.
Being able to critically reflect as a facilitator and impart this skill to healthcare teams in PD
work provides a foundation for enhancing and changing practice, enabling self growth and
providing evidence for change.

3.4 Reflective Practice
Reflective practice is a process of understanding, learning and taking action. The aim of
reflection is to enable individuals or groups to examine everyday situations with a view to
analysing the following:
Why did they
act in a particular
way?
Was this
the best way
to work?
What
information/
evidence/
experience led
them to act in
this way?
What effect
did it have on
the resident/
individual?
An essential component in PD work is the adoption of reflection as an integral part of each
healthcare professional’s role. To enable this process to be real, skills and knowledge need to
be nurtured and expanded. One of the aims of reflective practice is to provide opportunities
in which learning from experience takes place through a structured framework in a
supportive manner. Through reflection, an individual can explore their working environment;
see themselves in the context of their practice and the ‘way they work’. This provides them
with the opportunity to stand back and try to make sense of the experience and to question
what it is they do and what they would like to do better. Overall, reflective practice is also
about learning and gaining new insight. In some circumstances, sharing that learning to
enhance practice or professional development.
Key questions to guide the reflective process include:
What was/is the experience?
What did/do I feel about the
experience?
What options did/do I have?
What have they
learned from the
experience?
What other
options did they
have?
What
could/should
they do differently
in the
future?
What factors influenced my
experience?
How do I make sense of the
experience?
What have I learned about my
practice/myself/my organisation?
(Adapted from McCormack, 2006)
According to Johns (2009) reflection-on-experience is a window for practitioners to look
inside and know who they are in the context of their practice. Practitioners may have the
opportunity to expose, confront and understand the contradictions within their practice.
It is the conflict of contradictions and the commitment to achieve desirable work that
empowers the practitioner to take action to appropriately resolve these conditions. Jarvis
(1992) identifies time to reflect and the ability to reflect as essential ingredients necessary
for effective reflection.
21

Before reflection can take place, the experience has to be processed for it to be meaningful.
The stages of reflection involve self awareness, critical analysis of feelings and knowledge,
and the creation of new perspectives on practice issues and individual knowledge. There are
many models of reflection. Dewey (1933) in his work suggested the following perequisites
necessary to undertake reflection:
• Willingness to learn
• Commitment
• Motivation
• Open mindedness
For the purpose of this guide, the Gibbs reflection model (1988) will be used as a framework
and example of a reflection undertaken. Key skills associated with reflection are illustrated
in Figure 3.1.
Figure 3.1: Skills associated with reflection
22
Analysis
of Feelings
What were you thinking
and feeling?
Evaluation
What was good and
bad about the
experience?
Conclusion
What else could you
have done?
• Responsibility for own learning
• Consider all sides of an argument
• Consider the outcomes of actions you
might wish to undertake
Self Awareness
Description of
the Situation
What happened?
Analysis
What sense can
you make of the
situation?
Action Plan
If it arose again, what
would you do?
(Gibbs, 1988)

Figure 3.2: Gibbs Reflective Cycle
Action Plan
If it arose
again what would
you do?
Conclusion
The following is an example of a reflection using Gibbs reflective model.
Stage 1: Description of the event
Description
What happened?
Description
What sense can
you make of the
situation?
Feelings
What were
you thinking &
feeling?
Evaluation
What was good
& bad about the
experience?
(Gibbs, 1988)
Describe in detail the event you are reflecting on.
Include for example: where you were; who else was there; why were you there; what you were
doing; what other people were doing; what was the context of the event; what happened;
what was your part in this; what parts did the other people play; what was the result.
Reflective event
A woman, aged 60 with multiple sclerosis, is a long-term patient on our ward. One evening,
she said to me “Would you mind texting my son for me? He hasn’t been in contact for a while
and I wonder if he is OK”. This lady has no use of her hands or legs. I said “no problem” and
typed the text message for her and at the end she said “love mom”.
Stage 2: Feelings
At this stage in the process, recall and explore the things that were going on inside your
head i.e. why does this event stick in your mind? Include how you were feeling when the
event started; what you were thinking about at the time; how it made you feel; how other
people made you feel; how you felt about the outcome of the event; what you think about
it now.
Response
“I was thinking at the time how vulnerable and perhaps embarrassed she must feel in asking a
staff member to text a private message. I felt that my heart went out to her being so powerless
and some of the things that we all take for granted which she does not have the ability to do. I
23

could see the worry on her face at the time and I really identified with her, being a mother myself.
I put myself in her shoes, thinking how it would feel not being in contact with your family all the
time but being in a bed not able to move but still being able to worry”.
Stage 3: Evaluation
Try to evaluate or make a judgement about what has happened. Consider what was good
about the experience and what was bad about the experience or what did not go so well.
Response
“I suppose I realised how much we all take for granted and also I felt a bond that she was
comfortable enough to ask me to do this. It was bad because I felt how unfair life was to this
lady. I suppose she says herself that she has accepted her illness now and does not wish to be at
home”.
Stage 4: Analysis
Break the event down into its component parts so they can be explored separately. You may
need to ask more detailed questions about the answers to the last stage. For example, what
went well; what did you do well; what did others do well; what went wrong or did not turn
out how it should have done; in what way did you or others contribute to this?
Response
“I suppose I could have rung her family and asked her son to give her a ring but I sensed she didn’t
want to me to do this and it would be very wrong to go behind her back”.
Stage 5: Conclusion and action plan
This differs from the evaluation stage in that now you have explored the issue from
different angles and have a lot of information on which to base your judgement. This
evidence may come from many different sources, such as, literature or others who have
had similar experiences etc. It is here that you are likely to develop insight into you own
and other people’s behaviour, in terms of how they contributed to the outcome of the
event. Remember the purpose of reflection is to learn from an experience. Without detailed
analysis and honest exploration that occurs during all the previous stages, it is unlikely that
all aspects of the event will be taken into account and, therefore, valuable opportunities for
learning can be missed. During this stage you should ask yourself what you could have done
differently, acknowledging your own learning and insight gained.
During this stage, you should think of yourself in the future encountering this type of event
again and plan what you would do – would you act differently or would you be likely to do
the same? Here the cycle is tentatively completed and suggests that should the event occur
again, it will be the focus of another reflective cycle.
Response
“If it arose again I would do what she asked and would again empathise with her on how difficult
her situation is”.
(Source: Jasper, 2003)
24

Models of reflective practice are sometimes seen as being prescriptive and reducing
experiences to just answering a set of questions. However, practitioners are encouraged to
use an appropriate model of reflection in a way most helpful to them. The ability to foster
alternative approaches such as creativity and poetry is very positive. Individuals need to be
supported and guided through the process of reflection when using any of the frameworks
for the first time. By participating in structured reflection, professional and personal
development will evolve through assisting healthcare team members to value their practice,
critically evaluate care and their own individual or group journey holistically.
3.5 High Challenge/High Support (HC/HS)
For change in culture/practice to occur, all of the team must be open to challenging
practice and to adapt in a positive and effective way. Challenge must not be focused on
humiliating or belittling anyone but in respectfully supporting individuals to change to
agreed new practices. It is not about saying ‘you can’t do that’ or ‘you were wrong there’ but
instead asking questions to raise awareness such as, ‘I noticed that you were doing ….. and
wondered if you were aware, we have agreed not to do this anymore’. The purpose of asking
questions is to seek clarity, inform action and support effective decision making. In practice
where challenge is avoided, there is very little innovation and care is not person-centred. It
is important that the healthcare team recognise and accept challenge in a positive way.
Effective challenge is:
• Non confrontational
• Non critical
• Non judgemental
• Emotionally balanced
• Supportive
• Empowering
• New learning
The HC/HS grid (Figure 3.3) is a visual representation of what it means to effectively challenge
and what happens to an individual when challenge is not approached effectively.
25

Figure 3.3: High Challenge/High Support Grid
26
HIGH
Challenge
RETREAT GROwTH
STASIS CONFIRMATION
LOW Support
HIGH
Source: Daloz (1986)
Effective challenge is non-aggressive, non-combative and deeply supportive with the
intended outcome of enabling learning.
• High challenge/high support leads to environments that are productive.
• Low challenge/high support leads to environments that are harmonious in a negative
and destructive way.
• High challenge/low support leads to environments that cause burnout.
• Low challenge/low support leads to apathy.

3.6 Example of an activity to introduce the process of
High Challenge/High Support (HC/HS)
This is an example of an activity session to introduce the process of challenge and support in
practice. This session can be incorporated into a PD group meeting, or in a ward or practice
area. It is important to allow 1-1½ hours to carry out this activity. Within this example, the
healthcare team is referred to as the PD group but this can be adapted to include a smaller
cohort (more than two). Using HC/HS in the change process is a skill which is built up over
time as the PD facilitator will become more experienced, knowledgeable and confident.
This is an example of what the activity will look like with suggested timings:
1 Introduce the activity and its purpose to your group. Introduce the HC/HS grid
and generate discussion around each of the sections through role playing, taking
examples from their workplace or a situation that one of the group members may have
experienced. At the beginning of this exercise, schedule time for a group discussion at
the end to evaluate this type of process and the facilitation skills needed.
2 15-20 minutes – In small groups of 2/3 ask the participants to describe what challenge
and support means to them. The discussion should also centre on the positive and
negative points about each of the areas. The aim is to establish a summary description
of both challenge and support.
3 15 minutes – Ask the groups to discuss what happens when:
There is too much challenge and not enough support.
There is too much support and not enough challenge.
Ask them how they feel their individual department or larger organisation deals with
challenge and support.
4 10 minutes – Introduce the challenge and support grid and talk through the four
sections. Use real situations to demonstrate each of the sections. Encourage the group
members to participate and suggest they offer some real life examples or situations
they have come across to demonstrate this process. The group can then act this out in
role play.
5 45 minutes – Role Play. The facilitator of the group can lead this by role playing HC/
HS. Involve the group as much as possible, ensuring participants have an opportunity
to discuss and critique the role play. This can be the foundation for participants or
individuals to begin the process of HC/HS. It can be a very challenging experience and
support is required at facilitator level. The importance of having terms of engagement
is reiterated at this point and it is crucial to schedule time to debrief the role that you
are playing.
HC/HS is integral to PD work and will be revisited and reviewed at all stages of the PD
process of implementing change and enhancing care effectively. Throughout HC/HS, the
integral component is person-centeredness which involves supporting others and therefore
expanding learning.
27

3.7 Giving and receiving feedback
Feedback is a specific type of direct communication that is honest, balanced and supportive
for the person to whom it is offered (Dewing, 2008a). This section draws on detailed
guidance for healthcare teams when giving and receiving feedback, (Appendix 2) produced
by Dewing (2008a). Feedback is about learning, reflecting and changing. It is a necessary
facilitation skill for healthcare teams to understand and be aware of, particularly for leaders
and champions within teams so that they become skilful in carrying it out. Important aspects
of giving and receiving feedback include the facilitator acknowledging the level of challenge
and support that is required and the appropriateness of the feedback. Giving and receiving
feedback is based on knowing the person and concern for the relationship between both
people involved. This is a process and not a one off event; it is planned in advance and set
within ground rules. Central to this process are the following:
Mutual respect Confidentiality
Feedback should be factual, clear, concise and precise. It is not a chat; it is a structured
conversation or dialogue. The process is a face to face meeting usually between two or
more people; an example of this could be when an observation of care is completed and
the observers would arrange to give feedback to the relevant individuals. It is important
to prepare for giving and receiving feedback and prepare the healthcare team. Effective
feedback will enable the person receiving it to have the opportunity to listen, reflect and
think about options for action which will contribute towards cultural change. Principles of
feedback need to be established and accepted by healthcare teams.
Key points when facilitating feedback are:
• Involvement of appropriate members of the healthcare team and residents if relevant.
• Ensure the environment is appropriate and conducive to good communication.
• Be prepared to challenge in a supportive way, any expressions of dissatisfaction among
the healthcare team.
• Be knowledgeable and prepared to offer high support.
• Make explicit the consequences in relation to responsibilities and accountability.
• Consideration, as a facilitator, for those receiving feedback who may not have
experienced the process before.
• How team members not present can be actively included and participate, such as,
arranging alternative times.
28
Reflection and
Learning
Conditions for
Empowerment
Practical
Aspects of the
Environment

Section 4 Changing the Culture
and Context of Care - Collecting
the Evidence
4.1 Introduction
This section provides information on establishing the PD group. It also outlines the processes
that are used to collect evidence from the practice area to enhance care and inform the
action planning stage. In order to initiate a change in the culture and context of care,
evidence from practice must be gathered to inform the change and provide a foundation to
work from. Appendices are included where applicable.
4.2 Commencing the process or the programme
One of the first stages is to have a plan for what you would like to do. This will establish a
starting point for all involved in order to identify mutually agreed aims, objectives and ways
of working. This may involve the following:
- Having an understanding of the purpose or context for the PD work. This may be
linked to ongoing development work, service/organisation improvement initiatives,
to the HSE strategic vision or other relevant legislation/strategy.
- Identifying key stakeholders both inside and outside the organisation e.g. residents,
DON, service manager, clinical nurse manager, staff nurses, healthcare assistants
and physiotherapists. The identification of key people will assist and support the PD
group on the journey.
- Developing an understanding of PD, the processes involved and the three key
underpinning principles – Collaboration, Inclusion and Participation (CIP). The need
to continue to build on knowledge and skills is critical to working towards changing
the culture and context of care. This can be achieved, e.g., through networking with
colleagues, reading literature, sharing work and discussing challenges that you
come across.
- Obtaining a commitment to engage in the PD work may involve a written contract.
This approach was used by the national programme team.
- Securing the necessary time and financial resources.
- General communication to healthcare and administrative staff as well as residents in
relation to the PD work and what it means. This may be carried out in different ways,
for example; discussing the PD work at report time/handover, posters around the
wards or departments, through resident groups, residents’ newsletters, and email.
There are many other methods of communication which can also be used.
29

The next stage is to establish a PD group – this may not necessarily be a big group but
more than one person is necessary. The following steps are involved in establishing the PD
group.
4.3 Establishing the PD group - the steps
• Identify a person/facilitator(s) to lead the group.
• Identify key stakeholders who need to be directly and indirectly involved in the
PD process. This is a vital step in the process as it builds on using the principles of
Collaboration, Inclusion and Participation (CIP). A stakeholder is defined as anyone
with an interest in the project, such as:
• Invite volunteers to become members of the PD group (e.g. a multidisciplinary
group). This process was used in the national programme in each of the participating
residential settings.
• Agree a date, time and venue for PD group meetings and arrange invitations and
agenda. Appendix 3 provides an example which can be adapted depending on your
needs and a template for a PD meeting/workshop.
• At the first meeting the facilitator should welcome and initiate introductions, a group
opening exercise should be included on the agenda. This “icebreaker” is a short
process or structured activity which can be approximately 10-15 minutes in length. It is
designed to:
30
Manager
Nurse
• Enhance introductions within the group.
Carer
Resident
Healthcare Assistant
• Put participants and facilitators at ease so they get to know each other.
• Encourage different methods of communication with creative and fun exercises.
• Generate energy and enthusiasm for the PD work.
It is important to link the opening exercise/icebreaker to the theme of the PD workshop.
Resources required for an opening exercise may include materials for creative tasks.
Alternatively ‘pick a word that best describes how you feel today’ or ‘find out three things about
the person sitting next to you’. There are many activities that can be used with a group and
there are existing valuable resources available.
Establish the purpose of meeting and agree terms of engagement (Figure 4.1). This can also
be a creative exercise, using colours or art as part of the group work. The following provides
an overview of this process.

4.4 Terms of engagement (ground rules or contract)
Group members work together towards a defined end/goal and, at the same time, focus on
how they are co-operating to ensure the development and support of each other within
the group. It is important that terms of engagement (ground rules) are established at an
early stage in the group development. According to Wilkinson (2004), ground rules or
group norms are used to set an agreed standard of behaviour that guide how the group
will interact and behave towards one another. Figure 4.1 provides an example of terms of
engagement which were established for a PD group .
Figure 4.1: Example of terms of engagement for a PD group
Word Chosen
Responsibility
Strength
Courage
Terms of
Engagement
(meaning)
Ownership
Dedication
Knowledge
Accountability
Leadership
Change
Unity
Power
Trust
Positive
Limitations
Brave
Acceptance
Confidence
Authority
What would it
look/feel like
(actions)
Pride
Commitment
Learning
Follow through
Dedication
Challenges
Team/Solidarity
Encouragement
Open/honest
relationship
Optimistic
Insecurity
Open/confident
Honest
Individuality
Acceptance / Action
Consequences
(Outcomes +/-)
Confidence
Encouragement
Enthusiasm
Recognition
Empowerment
Fear/Enthusiasm
Achievement
Confidence/Success
Respect/Dignity
Loyalty
Optimism
Weakness/caring
De-motivation
Depth/meaning
True/honest
Freedom
Achievements
When drawing up the terms of engagement, do not assume agreement between group
members; explain each one carefully and check with the group that you have consensus
before they are accepted and signed off by the group. When the PD group meet, it is useful
to review or consider the terms of engagement at each meeting. This provides a framework
to evaluate the group development process. It is important to draw the group’s attention
to any of the terms of engagement that could be compromised during the PD meeting/
workshop and this can be done easily by discussing the particular points which need to be
highlighted. Over time, the terms of engagement can help a group become self–correcting
based on the group norms that have been established collectively.
31

Establishing the group and group processes sets the scene for effective change to take place.
The next stage involves developing a vision which is concerned with establishing values
and beliefs within a structured process.
4.5 Values clarification work – sharing and creating a
vision for practice
The next stage in PD work is to agree a common or shared vision for your practice area based
on clarifying values and beliefs of the healthcare team, residents and other key stakeholders.
Establishing a common vision collaboratively, puts in place a focus for all to work towards,
based on the purpose of the PD work being undertaken. Values clarification work then
unfolds into the creation of shared values and ultimately a vision statement that is specific
for the practice area/unit. This process is underpinned by international evidence (Dewing
2007; Warfield and Manley 1990). Values clarification work is important when embarking on
a quality initiative; it has at its centre the ability to include all stakeholders and key objectives
based on evidence and policy. Having the means to verbalise our values and beliefs, then
finding ways of putting them into practice can present barriers and challenges to healthcare
teams, but also provides an important focus for PD work.
This exercise is designed to access and clarify the values and beliefs that the healthcare
team, residents/families and other key stakeholders maintain about the ethos of care. It
is a facilitated inclusive process. A specific amount of time in relation to carrying out the
exercise should be allowed, taking into consideration the focus of the values clarification
work and the stakeholder group. The process and practical tools required are presented in
Appendix 4.
4.6 Observations of care
Conducting observations of care within the context of a practice setting provides a method
to understand the practice area in a more detailed way. This process is a learning activity
and a vital part of developing practice and a culture of person-centred care. The healthcare
team is provided with an opportunity to step outside their usual role of ‘doing’ and observe
the working environment from a different perspective. In many instances familiarity around
the environment and generally accepted daily routines become part of the provision of
care. Formally carrying out observations of care provides an opportunity to look, listen, hear
and review practice in a different way. A formal and evidenced based framework was used
in the national programme. Relevant documentation templates and the Workplace Culture
Critical Analysis Tool (WCCAT), (McCormack et al., 2007a; 2009) are presented in Appendices
5 and 6. The aim of this framework is to inform the degree to which changes in practice can
achieve a change in culture and context of care.
32

Carrying out observations will assist the healthcare team gain a greater insight into whether
the care provided is person-centred or not for the resident/family and the team itself.
Exploring practice, raising consciousness about taken for granted practices and assumptions
and reflecting on them are key components of the observation process. These activities
highlight the need to see things from a different perspective and to facilitate the delivery
of person-centred care within person-centred environments. Using reflective cues and
facilitation will enable the healthcare team to reflect on how they practice and what they take
for granted. This is a very important learning exercise which everyone including residents,
families/carers can engage with. In order to undertake this activity, a communication
process must be carried out to inform residents, healthcare staff and other key stakeholders
of the planned observation. One or two people are required for the observation of care,
however, all members of the healthcare team may be involved at different stages.
4.7 Environmental observation
The purpose of conducting an environmental observation is to allow the healthcare team
to explore how person-centred the environment is for residents and how effective it is for
healthcare teams to work within. This process is an active learning exercise. It is similar to
the principles of observations of care where communication and information is distributed
to key people to inform them of the process. The information collected can be used to
inform the development of a more person-centred culture and environment. When carrying
out this activity it is important for observers to be aware of residents who have impaired
physical and cognitive ability and how this impacts on their life.
Key points to include when arranging the activity
• Look at the environment from the perspective of the older person.
• Prior to carrying out this exercise, explain to the healthcare team, residents/families, and
other key stakeholders that you will you be carrying out environmental observations/
walkabout to help understand what it might be like to live here as a resident or visit on
a daily basis.
• Look at the organisation’s vision statement, the use of phrases like “Homely
Environment”, “Welcoming for family” etc and then look at the environment in that
context. This should raise discussion and awareness around these issues.
The person carrying out the environmental exercise should use the following as a guide. It
is based on recommendations for good practice from Dewing (2009a).
– Space – tidiness and clutter
– Decoration – colours, contrasts and style
– Care and attention given to an area or space
– Lighting – natural and artificial
33

– Noise levels – radio, television, noisy equipment
– Person-centred language – Do you hear person-centred language?
– Smell – Are there odours? Are they pleasant or unpleasant?
– Signage - How clear are the signs for residents and visitors? Are they welcoming and
effective?
– Art work and aesthetic ambience - How homely is it? How appropriate if you are
looking at person-centred care?
– Is it warm and inviting/homely?
– Is the environment organisation-focused or resident-focused?
– Flooring, furniture and furnishings, corridors
– Is there access to the outside gardens? Are there walking pathways?
– Day and dining areas - How would you describe them?
– Toilet and bathrooms - signs, privacy, locked doors
– Bedrooms or bed areas – How personalised are they? Routine use of bed rails
– Other spaces and rooms
– Shops and cafes
– Hairdressing - Does it look like a conventional hairdressing salon? What would you
expect to see when you stand outside a hairdressing salon?
– Specific features relevant to people with impaired vision, hearing, mobility and
cognition dementia
When facilitating an environmental observation, ask questions that will promote reflection.
For example:
34
How does this fit with being person-centred?
Is there a balance between risk and freedom of movement here?
What does storage of walking frames in the day room say to older people
about who this space is for and how we value this space?
At the end of the environmental walkabout, arrange to give feedback after analysing the
evidence with the relevant staff. Then work together to develop an action plan to change
and enhance the environment.

4.8 Person-centred language exercise
The language that is used within a healthcare setting reflects the level of person-centredness
within the practice area. Language includes the spoken and written word as well as body
language. A language learning activity can identify what language is most acceptable,
less acceptable or unacceptable. This is usually agreed with the involvement of all staff.
The use of ‘demeaning’ language, although not intended to hurt, can be distressing to
adults receiving care. Using words such as ‘cot sides’, ‘nappies’, ‘beakers’, ‘bib’s etc. can be
offensive. The use of terms of endearment is also often tolerated by older people but can
depersonalise them and be unintentionally disrespectful. So words like ‘darling’, ‘love’, ’pet’,
‘granny’, ‘granddad’ etc. are not used in a person-centred culture and need to be challenged
when they do occur in any context. If nurses or healthcare assistants are asked what name
they prefer to be addressed by, they are unlikely to say ‘love’ or ‘pet’. Healthcare teams have
a responsibility to challenge each other if the correct terms are not being used. Challenge
in PD is always respectful and supportive. For members of the healthcare team, terms of
endearment can be demeaning and hierarchical without intent and sometimes with intent.
This is not conducive to person-centred culture. Not referring to colleagues by their names
and referring to them as ‘the girls’ or ‘the lads’ is not person-centred and can indicate a
lack of respect. Regardless of the intention of the person using these words, individuals
generally prefer others to use their given name. Other words/terms such as ‘feeding’, ‘feeds’,
‘toileting’, ‘heavies’, ‘the lifts’ etc. also de-personalise older people. In a person-centred
culture, nurses, healthcare assistants and other support workers recognise that adults/older
people need assistance with their meals and not ‘feeding’; individuals are assisted to the
toilet and not toileted; individuals are not referred to as objects such as ‘feeders’, ‘heavies’
and other demeaning terms. All individuals, both residents and members of the healthcare
team should be treated with dignity and respect.
The following framework will provide the basis for the person-centred language exercise to
be carried out. The aim is to assist members of the healthcare team explore person-centred
language in their day to day work of caring for residents, while interacting together to put in
place processes where this language becomes the culture of the organisation.
Person-centred language exercise:
• Identify a facilitator to lead the exercise.
• Discuss the aim and purpose of this exercise together as a team and plan to involve
older people.
• Provide short information sessions to discuss the aim and purpose of the exercise and
answer any questions; this will provide a basis for the work to proceed. A short leaflet
may be used to share information with staff.
• Use a flip chart and identify one or more members of the team to take responsibility for
their respective working area.
35

• Ask the team to contribute, for instance, by using ‘post-it notes’ to consider language
36
which is person-centred and examples which are not. This information can then be
discussed and an agreement on acceptable person-centred language can be reached.
This is a continuous process in PD to promote and strive towards a person-centred
culture.
• A further extension of this work may be promoted through the development of a
poster(s) on display in different areas of the organisation. This was one of the learning
activities completed in the national PD programme.
The following activity outlines how the healthcare team can gain a deeper insight into the
lives of the residents in a person-centred way through resident narratives or stories.
4.9 Resident narratives/stories
Narratives or stories with older people are interviews which provide the older person with
the opportunity to talk about their experience of life or knowledge, highlighting anything
that is important to them and/or what they like and dislike about where they live. This is a
formal process and must be undertaken with consent and full understanding of both the
ethical implications and requirements involved. Information is collected and analysed;
a feedback process is activated by the facilitator. This information can then be used to
change or improve practice/care provided (Hsu and McCormack, 2006). The interview is
unstructured; an example of an opening question for an older person living in a residential
unit could be ‘What is it like to live here?’ Examples of interview questions can be found in
Appendix 7. The interview is usually recorded in writing or taped. The analysis is carried
out through a formal process of theming the data to produce findings. This in turn forms
the feedback to the relevant healthcare team and ultimately informs the change process
through action planning. Residents are valued in residential settings and their opinions
and needs are important, this is one way of involving residents in their care directly. The
provision of a mechanism for feedback must be facilitated in a person-centred way. A formal
framework and ethical approval process provide an important structure for this activity
(Hsu and McCormack, 2006).

4.10 Quality of life exercise
“Cats, skirts and lipstick”
This quality of life exercise is helpful in getting to know older people in a meaningful way.
It was originally developed in the pilot PD programme by a participant from St Mary’s,
Mullingar. It is about getting to know the person in a more in-depth way and reflecting
on what they would like the healthcare team to know about what is important to them.
This information assists the healthcare team to be more person-centred in their care for the
individual person.
This exercise involves asking the individual resident three things/activities that are important
to them in their day-to-day life. As a learning activity one of the participants in the pilot
programme in Mullingar identified the three things she would want staff to know about her
if she was admitted to residential care. She has an absolute fear of cats; she never wears a
skirt and would become upset if this changed. Also, the participant loves to wear her lipstick
daily. Hence the name ‘Cats, skirts and lipstick’ was established for this exercise.
The purpose of this creative exercise is to determine how accessible important items or even
routines are for the resident. The healthcare team is responsible for ensuring that residents’
needs are met in a person-centred way. Along with other exercises outlined in this document,
this is a simple yet very effective way of getting to know the older person. Any member of
staff can be involved as well as residents’ family and friends. It is a facilitated process either in
a group or one-to-one. Appendix 8 provides an example of another creative exercise – “my
day, my way” that can also be used to explore and enhance quality of life.
37

4.11 Life story work
The aim of this exercise is for the healthcare team to get to know more about the resident’s
life, their values and beliefs and what matters to them. Life story work is where one person
shares information about their life with another and then it can be presented in the form of
a booklet or pictures. It promotes a shared sense of identity that helps the healthcare team
to be motivated and committed to providing more personalised care for the residents.
The healthcare team is facilitated to learn about events or situations in the resident’s life,
either in the present or past. This could be something ‘everyday’ such as a job or the form
of work they did, a trip they went on years ago or since they commenced living in the
residential unit. This information can be captured through photographs, a short account,
poem, painting or collage. Families/carers can get involved in this worthwhile project. Once
the life story work is completed it belongs to the resident and requires their permission for
sharing. If the resident wishes, it can be displayed for others to share either in the corridor
or in the sitting room/dining room or it can be exhibited in their room. It is another method
of getting to know residents better and letting them share their valuable experiences of life.
This can initiate the start of interesting groups sharing experiences within residential units
or in the community.
The need to collect evidence from practice and individual residents is critical to this process
as it provides a strong foundation from which to work. The exploration of care environments
and individual lives of residents in the form of resident narrative, observations of care or
life story work provides the healthcare team with evidence acquired through systematic
processes. This can help to provide a service which is person-centred and establish a caring
culture which meets individual needs. The activities described were used as part of the
national programme but it is recommended that further reading is undertaken and ethical
considerations are taken into account.
38

Section 5
Evaluating Change and
Enhancing Practice
5.1 Introduction
In PD work, all changes and developments must be open to evaluation to assess their impact and
effectiveness. The intention of this section is to provide an overview of PD evaluation strategies
which are integral to enhancing practice.
5.2 What is evaluation in Practice Development?
In the context of PD work, evaluation sets out to determine if something is of value through
systematic and evidence based frameworks. There are many ways of undertaking this process,
depending on the type of development or change taking place. Effective evaluation in PD
initiatives has stated objectives, clear steps to achieving these objectives, and a process to ensure
that the effectiveness of the steps can be measured. The process may include multiple methods
that will allow feedback on whether the processes and changes in practice have been successful.
Evaluation in PD has a wider scope than the traditional measuring methods. All evaluations of care
practices in cultures that are person-centred will involve the service user. According to McCormack
et al., (2004) this process of evaluation when correctly facilitated enables healthcare teams to
identify organisational barriers to innovation and change. The action planning template included
in Appendix 9 provides a framework which can be used for the evaluation process. Evaluation in
PD involves the healthcare team and residents evaluating the impact and outcome of practice
changes for service users, the healthcare team and the organisation.
Evaluation is the collection, analysis, interpretation and dissemination of information about any
aspect of the practice area; this needs to be carried out in a structured way. Wilson et al (2008)
point out that evaluation in PD can help to:
• build PD theory
• generate knowledge through a systematic approach
• inform and refine ongoing developments within the practice area
• sustain the change
• transfer ideas, processes and strategies
• identify what works and what does not work
39

• develop political skills which may be needed to support ongoing PD work
• increase opportunities for funding projects by articulating and demonstrating the
process of change/transformation
5.3 Developing an evaluation strategy
When developing an evaluation strategy the following framework may be considered.
(P.R.A.X.I.S):
• Purpose of PD work
Identify clearly the aims and objectives of the work. Also be clear about the purpose
of the PD initiative. Identify who needs to be involved and what methods you may
need in the evaluation process. Having a clear purpose will help identify potential or
anticipated outcomes.
• Reflexivity
Critical questioning and reflection about the evaluation process. This will enable
the practitioners to have insight to and consideration of alternatives, allow greater
understanding and will help the individual’s personal development and growth.
• Approaches
The approach chosen for the evaluation needs to fit with both the values and beliefs of
the residents/healthcare team/organisation.
• ConteXt
The need to consider the context in which the evaluation is to take place and ensure
that it is part of the evaluation process. This includes any local knowledge around the
inquiry, what are the resources and time factors? Do any political factors need to be
taken into consideration? Paying attention to the context may help understand some
of the cultural anomalies that can influence people’s reaction and behaviour towards
the evaluation.
• Intent
The need for participants to be clear about the intent of the project will provide clarity
on the intent of the evaluation. The intention is linked to the purpose, reflexivity and
the approaches that may be needed for the evaluation.
• Stakeholders
Identify who should be involved, who has a stake or interest in the evaluation. Consider
the types of questions that identified stakeholders might have about the programme.
40
(Adapted from wilson et al., 2008)

It is important when planning a PD initiative to prepare and agree what evaluation framework
will be used. The tools and approaches that may be needed can then be identified. Questions
to guide the process are outlined below.
Questions to guide the process of evaluation
• Did it work?
• What has been achieved?
• How was it achieved?
• If the plan was not achieved, what were the barriers/obstacles?
• What was the learning?
• What do we do now?
• How will we do it?
• Who will support/challenge us?
• How will we evaluate?
The evaluation approach as described by Guba and Lincoln (1989) exploring Claims,
Concerns and Issues (CCIs) can be used in this process.
5.4 Claims, Concerns and Issues (CCIs)
CCIs can be carried out as part of a formal evaluation. CCIs can, for example, be used to
evaluate how effective a meeting was or can be used to set an agenda for a meeting. Issues
that arise on the ward can also be addressed using CCIs. This framework originated from
Guba and Lincoln’s (1989) Fourth Generation Evaluation work (McCormack et al., 2004).
• Claims are favourable assertions about the topic you are evaluating.
• Concerns are any unfavourable assertions about the topic and its implementation.
• Issues are questions that any reasonable person might ask about the topic and its
implementation and usually arise from concerns.
When considering the issues, the PD group should use ‘How’ and ‘What’ statements to address
the questions identified. For example, if the concern was about poor communication within
the unit the question could be:
• what can we do to improve our communication?
• How can we ensure that our communication within the unit is more effective?
The framework for CCIs is presented in Appendix 10.
41

5.5 Problem solving framework
There are many different problem solving frameworks in use by different organisations;
details of one of these frameworks are provided below. The framework for this guide is
adapted from the Leading and Empowering Organisations (LEO) programme (Creative
Healthcare Management, 2003). This framework can be used to help address/resolve an
issue/problem. An appropriate amount of time should be allocated to work through this
process. It is important that one person in the PD group takes the lead to facilitate the
process and this can be rotated as necessary. Capturing the notes from the process on a
flip chart can then be shared and used as a framework. The following is adapted from Bens
(2005).
Step 1 – Define the problem
Successful problem solvers spend more time thinking about and defining the problem
• What is happening?
• Why is it happening?
• Who is involved?
• How do the people involved see it?
Step 2 – Identify potential options and their consequences
Troubleshoot the plan by using a blank sheet to identify all of the things that could get in
the way and then ensure that there are plans in place to deal with them.
Step 3 - Develop an action plan
• Identify the specific steps needed to implement the chosen solutions.
• Specify how things will be done, when and by whom.
• What are the specific steps which need to be taken?
• What is the timeframe for each step?
• Who will carry out the plan?
• What do we need to help us with it?
• What skills are required?
• What resources should be used?
• What knowledge is necessary?
42

• When will the evaluation be conducted?
• Who needs to know about the plan?
Step 4 – Evaluation
How did we do?
• What has our learning been?
• What would we do differently next time?
• How did the processes work?
• What has been the impact?
It is only by understanding and using the framework that you can become familiar and
comfortable with using it. The important thing to remember is that consensus decision
making creates a win-win situation based on all sharing their opinions while considering the
ideas of others. It means all members of the group are committed to take a step in unison to
solve a problem. Problem solving can be challenging for teams but it is a necessary part of
the process of implementing change successfully.
5.6 Importance of celebration and sharing praise in
Practice Development
Alongside evaluation and problem solving, healthcare teams also need to acknowledge
achievements. There are many opportunities along the PD change journey for successes
or achievements to be celebrated in different ways. An opportunity to celebrate may be
through sharing and networking with other colleagues nationally and internationally. This
can be in the form of presentations/publications initially at local level then expanding to a
wider audience. The importance of celebrating and sharing is inclusive for residents and
families, the healthcare team and key stakeholders.
43

Section 6
Conclusion
The requirement for healthcare teams to develop and enhance care for older people is
well established in policy and strategy in the Republic of Ireland. The establishment of the
National Quality Standards for Residential Care Settings for Older People in Ireland (HIQA,
2009) has identified the need for care providers to continue to strive towards the provision
of a person-centred approach.
The processes used in practice development provide a systematic approach to achieving
a person-centred philosophy of care. Skilled facilitation, leadership, reflective practice and
the inclusion of all key stakeholders, most importantly older people, are some of the key
components which are critical to enhancing care.
Older people must be involved in the decision making process along with the healthcare
team. The use of resident narratives, observations of care activities and life story work ensure
that residents are the focus of the delivery and organisation of person-centred care. The
development of people within healthcare teams is also essential to this process.
The Older Person Service National Practice Development Programme 2007-2009 used the
processes and tools outlined in this guide. It is envisaged that this guide may be used
as a reference and support for healthcare teams who are committed to developing and
enhancing care practices.
44

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50

Appendices
51

The National Programme
Team and Participating Sites
The national practice development (PD) team included nurse researchers from the
University of Ulster, nurses from the Nursing Midwifery Planning and Development Units
(NMPDU) and nurses and healthcare staff from 17 participating community hospitals where
older people reside or visit on a daily basis in Ireland. The following provides details of the
national programme team.
External Programme Facilitators
Professor Brendan McCormack
Professor of Nursing Research/Head of the Person-centred Practice Research Centre and
Director of the Institute of Nursing Research, University of Ulster, Northern Ireland.
Professor Jan Dewing
Head of Person-centred Research and Practice Development/Professor East Sussex
Community Health NHS/Canterbury Christchurch University, Kent, England, Honorary
Research Fellow, University of Ulster, Northern Ireland. Visiting Professor of Aged Care and
Practice Development, SNMIH/University of Wollongong, NSW Australia.
Nursing and Midwifery Planning and Development Unit
(NMPDU) Facilitators
• Elizabeth Breslin NMPD Officer, Nursing/Midwifery Planning and Development Unit
(NMPDU), HSE West, Ballyshannon, County Donegal.
• Ann Coyne-Nevin Assistant Director of Nursing, St Patrick’s Hospital, HSE South East,
Waterford.
• Kate Kennedy NMPD Officer, NMPDU, HSE South, Cork.
• Mary Manning NMPD Officer, NMPDU, HSE Mid Leinster, County Offaly.
• Lorna Peelo-Kilroe National Practice Development Coordinator, End-of-Life Care,
Hospice Friendly Hospital Programme, Dublin.
• Catherine Tobin Post Graduate Diploma/Programme Facilitator, NMPDU, HSE North
East, County Louth.
52
Appendix 1

Participating Sites
The following is an overview of the participating sites.
PARTICIPATING PROGRAMME SITES INTERNAL FACILITATOR
Birr, Community Nursing Unit
County Offaly.
Cappahard Lodge Residential Unit of Old Age Psychiatry
Ennis, County Clare.
Carrigoran House Nursing Home
Newmarket-on-Fergus, Clare.
Community Hospital of the Assumption
Thurles, North Tipperary.
Falcarragh Community Hospital
Falcarragh, County Donegal.
Sacred Heart Hospital
County Carlow.
St. Brigid’s Hospital
Shaen, County Laois.
St. Columbanus Home
County Kerry.
St. Columba’s
Thomastown, County Kilkenny.
St. Finbarr’s Hospital
Cork.
St. John’s Hospital, Enniscorthy
County Wexford.
St. Joseph’s Hospital
Ardee, County Louth.
St. Joseph’s Unit, Bantry General Hospital
Bantry, County Cork.
St. Joseph’s Hospital
Trim, County Meath.
St. Mary’s Hospital
Castleblaney, County Monaghan.
St. Patrick’s Community Hospital
Carrick-on-Shannon, County Leitrim.
St. Vincent’s Hospital
Mountmellick, County Laois.
Aine Clancy
Anne Wilmott
Michelle Hardiman
Marie O’ Malley
Marian Ryan
Mairead Greene
Sheila Doherty
Donna Ward
Mary Farrell
Maura Byrne
Breda Davies
Georgina Bassett
Catherine Buckley
Deirdre Lang
Marie Caplice
Clare McCarthy
Ros Farrell
Rose Mooney
Mary Farrell
Freda Flynn
Teresa McDermott
Eva Boddy (1st Year)
Clare McLaughlin
53

Figure 1: Map of Participating sites
mary of Outcomes:
ndings nationally from the combined evaluation approaches the
g areas were identied:
ositive role of the NMPDU facilitator and the internal facilitator
54
ing collaboratively and in partnership with residents/families and
hcare teams.

Appendix 2
Feedback Guidance
Feedback is a specific type of direct communication that is honest and balanced, supportive
for the person it is offered to, yet challenging about an issue. The level of challenge and
support needs to be appropriate for the person it is being offered to. It is based on knowing
the person and concern for the relationship between both persons.
Feedback is planned in advance and set within ground rules central to which are the
values of mutual respect, confidentiality, reflection and learning, and the conditions for
empowerment.
Feedback is a process not a one off event.
Feedback is offered in such a way that is factual, clear, concise and precise. It enables the
person receiving it to have the opportunity to listen, reflect and think about options for
action that contribute towards cultural change.
The person receiving feedback is enabled to feel they have freedom to take action, consistent
with practice development principles and will be supported to do so.
The consequences arising from feedback in relation to responsibilities and accountability
need to be made explicit.
Feedback has multiple benefits; for the person receiving, the person offering it and for team
working.
Feedback is not a personal attack or personal criticism, nor is it a punitive intervention. It is
not about complaining or pursuing individual agendas.
Ultimately the giving and receiving of feedback needs to be a core high challenge and high
support process in a person-centred culture.
55

What is feedback?
Feedback is a direct, structured, real and honest conversation. There is a feeling of being
listened to and responses being valued. What is offered in feedback then provides
information or learning material for the person receiving the feedback to reflect on, learn
from and do something about.
The communication in feedback is honest and balanced, supportive for the person it is
offered to, yet challenging about an issue. It generally takes place face to face and on a
one to one basis. Although within the practice development programme, feedback can
be a group activity that is facilitated in a sensitive way. Feedback from the evaluation data
gathering will be offered in a mix of one to one and team formats.
Feedback takes place within a structured conversation – or dialogue. It is not a chat. The
person(s) receiving the feedback need to listen without interruption until the feedback is
complete. There is then the opportunity to ask for further details or to ask a question.
It is not necessary or helpful to defend or refute what has been offered as feedback so long
as it is factual. Receiving feedback can feel emotional and intense (as it can for the person
offering it too). The person(s) receiving the feedback may wish to express how they are
feeling in the moment about the content of the feedback (not the person offering it) – but
do this speaking for themselves only. For example: ‘I feel …..’ not ‘We all feel……’.
The level of challenge and support offered needs to be at a level that feels appropriate for
the person it is being offered to. This is based on knowing the person and concern for the
relationship between both persons. The aim is to contribute to learning and consequently
to personal and professional growth. The level of challenge and support can be evaluated
at the end of the feedback as this will help for future feedback and demonstrates feedback
is a continuous process.
The person offering feedback needs to demonstrate an interest in the person, demonstrate
support for the person and aim to be inclusive. It should also demonstrate respect, sensitivity,
transparency and attributes of empowerment.
Feedback must be given directly and not through a third party. It should also be timely.
Feedback is not something to be feared as it is not criticism, negative, or cherry picking.
Neither is it a forum for complaining or releasing a backlog of problems, personal attack,
punitive or pursuing individual agendas.
Feedback needs to be balanced in that it should include some positives and should enable
time for the person receiving the feedback to respond. The person receiving the feedback
may need time to consider what has been said before responding. So sometimes planning
for some quiet time for processing the initial feelings and thoughts can be helpful. Then
there usually follows some dialogue which in turn is followed by development of action
56

points or action planning. During this phase it may be helpful to clarify expectations of
what actions are to be developed. Sometimes it may be helpful to set up a discussion and
action planning session after the initial feedback session, especially where a large amount
of feedback has been covered – such as with the evaluation data in this programme.
How does feedback look and feel when it goes well?
People generally say they feel valued and validated as feedback lets them know what they
are doing well (and how well) and how that is appreciated. Feedback also shows the areas
(or our ‘blind spots’) that can be developed further.
When a person offers feedback to another, it means that the person offering the feedback
values and trusts the person to whom they are offering it. In a way it is a form of positive
affirmation. Feedback is given in such a way that it has room for options and a sense of
freedom about actions that can be taken. However, this must be set within a professional
framework, so there needs to be a mutual acknowledgement of responsibility and
accountability.
When feedback goes well there is a sense of experiential learning and space for reflection.
There is also the sense that the feedback is relevant for the person at that time, as it is based
on knowing the person.
When feedback goes well, there are positive consequences for both parties. It can also
contribute towards cultural change in that it enhances the conditions of empowerment
and collaborative working. It also provides opportunities to take action and demonstrate
accountability.
How does feedback look and feel when it
goes wrong?
This will be experienced as poor or negative communication. It will be generally unhelpful
either from how it is given or the content of the feedback itself. For example it might be
unstructured, unconstructive, dishonest and probably seem uncaring. It can lead to feelings
of being demoralised, hurt and even angry.
Feedback can also go wrong because the person receiving the feedback becomes angry
and defensive and feels that the feedback is a personal attack (even when feedback has not
been offered in that way). If the person receiving the feedback is not prepared or able to be
open to it and thus is closed or excessively guarded, this can lead to a negative exchange. It
is important for both parties to be able to express feelings but this must not result in a war
of words.
57

When feedback goes wrong it can destroy individuals, the team and destroy projects. It
may fuel existing grapevines about a ‘blame culture’ and have a negative impact on morale
and future planning. There tends to be a loss of respect which impacts on relationships and
personal growth. With repeated and unfair negative feedback people give up.
The contribution of different stakeholders for feedback
in the PD programme
All participants need to develop a respect for the process of giving and receiving feedback
as a process in PD. This requires staff to commit to understanding what feedback is, how it
works and to work with agreed ground rules with feedback.
Everyone involved in the PD programme has a role and responsibility for feedback.
Programme leads, facilitators, participant’s director of nursing and clinical nurse managers
in particular should be actively engaging with and supporting the planned giving and
receiving of feedback.
Cues for Reflection
• How are you preparing yourself and colleagues for feedback from the evaluation
data?
• What feelings and thoughts do you currently have about feedback and how might this
influence how you work with feedback?
• How can you further develop skills in receiving and responding to feedback?
• How can you further develop skills in offering feedback?
• Who can appropriately support and/or challenge you about feedback in your
practice?
Reference:
Dewing, J. (2008a) Evaluation Strategy: Feedback Guidance – Unpublished.
Older Person Service National Practice Development Programme 2007-2009.
58

Appendix 3
Example of an Agenda for
PD Workshop and Meeting
Notes Template
Workshop Day 5 (midway point in national two year programme)
Aims
For participants:
• To re-engage and continue to work together effectively as a group.
• To undertake or review the group development work completed previously, and
discuss the action plan process.
• To complete an exploration of evaluation data and work in progress in relation to
action planning.
• To identify how older people and their families will be involved in the action planning
process.
• To undertake a reflective review of the programme to date from the point of view of an
individual, a resident and an organisation.
Intended Learning Outcomes
• Continue to work with terms of engagement within the group.
• Shared effectiveness of workplace learning activities.
• Critical review of the group and learning to date.
• Assessment of evaluation data collected to date.
• Detailed action plans in place which involve older people and their families.
• Clear understanding of the programme plan for year two.
• Plan to facilitate workplace learning activities between day five and day six.
59

60
Times Learning Activity
09.15 Welcome
Activity One:
Opening exercise
For example, collage – painting – portrait (decide on the theme)
Write yourself a letter about what you aim to do in year two
Discuss established terms of engagement for the group
Review and agree workshop agenda and theme; for example, action planning
09.45 Activity Two:
Feedback on day 5 workplace learning activities
Reflective work
Discuss identified areas of practice in relation to action planning
Discuss feedback on evaluation data from individual ward and department areas
Environmental walk about (some of which must include older persons and families)
10.45 Break
11.15 Activity Three:
Review group processes
Discuss giving and receiving feedback within the group
Consider who needs to be involved in the action planning groups
Carry out CCIs (Claims, Concerns and Issues)
12.45 Lunch Break
13.30 Activity Four:
Work with the evaluation data, exploring themes, evaluating processes used to collect,
analyse and feedback
Discuss action planning group’s work for next six weeks in detail
15.30 Activity Five:
Action planning for facilitation of active learning in the workplace
Facilitating small discussion groups/sessions with staff and residents about evaluation
data and discuss how this has been used to guide PD work
Consider making posters on action plans and display around unit/site, this exercise
is about sharing information with colleagues, residents, their families and key
shakeholders
16.00 - 16.30 Summary:
Action points; feedback to DON/ADON; buddies for absent group members - sharing
events and actions from today; significant learning from the day; evaluation of day
(including feedback for facilitators using Heron’s matrix)
Group closing activity, for example:
What is your significant learning?
What did you like least?
What did you like best?
Document and evaluate

Notes from PD Workshop/Programme day
Venue: .......................................................................................................................................................................
Date: ..........................................................................................................................................................................
Facilitator: ................................................................................................................................................................
Internal facilitators: ..............................................................................................................................................
Notes prepared by: ..............................................................................................................................................
Participants in attendance: ...............................................................................................................................
Name Area of Work Staff Grade
Apologies
......................................................................................................................................................................................
......................................................................................................................................................................................
Proposed learning outcomes for the day
......................................................................................................................................................................................
......................................................................................................................................................................................
......................................................................................................................................................................................
......................................................................................................................................................................................
Feedback from activities (list) and any significant group processes
......................................................................................................................................................................................
......................................................................................................................................................................................
......................................................................................................................................................................................
61

Significant learning/evaluation for participants (as identified by group)
......................................................................................................................................................................................
......................................................................................................................................................................................
......................................................................................................................................................................................
......................................................................................................................................................................................
......................................................................................................................................................................................
......................................................................................................................................................................................
Work based learning activities to be carried out and facilitated by the
programme participants in the period between workshop/programme
days
......................................................................................................................................................................................
......................................................................................................................................................................................
......................................................................................................................................................................................
......................................................................................................................................................................................
......................................................................................................................................................................................
......................................................................................................................................................................................
......................................................................................................................................................................................
Facilitator’s evaluation of the day using agreed framework
......................................................................................................................................................................................
......................................................................................................................................................................................
......................................................................................................................................................................................
......................................................................................................................................................................................
......................................................................................................................................................................................
......................................................................................................................................................................................
......................................................................................................................................................................................
Significant learning for facilitators from the day
......................................................................................................................................................................................
......................................................................................................................................................................................
......................................................................................................................................................................................
62

Appendix 4
Values Clarification Exercise
Planning the Values Clarification Exercise
In order to begin this exercise it is important to inform older people, families and the health
care team of the purpose of the exercise. A sample information leaflet, facilitator’s guide and
guide for developing a vision statement are included in the appendices.
Information leaflet for residents and healthcare staff
The purpose of this exercise is to explore your beliefs and values about person-centred
care and find out how we can work together towards the provision of a person-centred
philosophy for everyone. This exercise should clarify through a collaborative process the
vision for this unit/hospital/ward. It involves collecting information from the healthcare
team, residents, families/visitors and key stakeholders. Person-centredness is the culture
that we are striving to achieve. The process is as follows:
Five large posters have been displayed in the ward/unit. Each has a different question on
person-centred care. We would like you to write your response on one post-it note under
each heading. Please use one post-it note per suggestion. This will help us when we are
analysing and collating your suggestions together into a common vision statement or
philosophy for this organisation.
The pages will be on display for three weeks starting from (insert date). We encourage you
to take part in the exercise during this period. Every opinion is valued and your anonymity
is assured, as you do not have to sign your name. We would ask that you only answer the
questions at the top of each page and other issues not related to person-centeredness can
be dealt with at a later stage. We will then put all suggestions together and look for the
common themes to form our philosophy of person-centred care for this unit/ward.
If you want to find out more about this exercise please contact (name of person), for
example PD group leader or identified person in the organisation who can provide further
information. We will be happy to answer any queries you may have regarding this exercise
and assist you if required.
Thank you for your time and involvement.
__________________________Name of Person to Contact
63

A Facilitator’s guide - Values Clarification Process
The five questions to be answered for this exercise are:
1 I believe the purpose of (name of unit/ward) is….
2 I believe this purpose can be achieved by ….
3 I believe the factors that enable person-centred care are….
4 I believe the factors that inhibit person-centred care are….
5 Other values and beliefs I have about person-centred care are….
How to carry out the exercise and materials needed
Write one of the above questions at the top of a flip-chart page (needs to be flip-chart size
to fit the collection of post-it notes) so you will need five flip-chart pages in total to answer
these questions.
For each flip chart you will need to use a different post-it note colour, for example on question
one you may use yellow post-it notes, question two you may use blue post-it notes etc.
It is necessary and a good approach to keep the post-it notes the same colour for each flip
chart in case they get mixed-up when the group are theming them.
Ask people to only write only one suggestion per post-it note but encourage everyone to
write as many suggestions as they wish.
The information leaflet which will have been distributed prior to commencing this exercise
will provide assistance for the residents, families and healthcare team to understand the
purpose and process of this task.
These contributions from residents, the healthcare team and other key stakeholders will
form the philosophy and vision of care for the unit/ward.
Figure 1: Example of flip chart with key questions
I believe the
purpose
of personcentred
care is:
64
I believe this
purpose can
be achieved
by:
I believe
the factors
that enable
personcentred
care
are:
I believe
the factors
that inhibit
personcentred
care
are:
Other
values and
beliefs I
have about
personcentred
care

Collecting and analysing the data
This exercise will take a considerable period of time and organisation. Once the collection
of data is complete:
1 The facilitator should gather all the data/feedback and arrange this in an orderly way.
Time should be set aside to make this a group exercise involving for example, residents,
families, visitors and the healthcare team. This can be a creative and learning exercise.
2 Arrange the responses into common themes and identify any major patterns. Keep
responses which are not relevant to the questions asked for discussion at a later date.
You are now ready to create the vision statement.
Start the vision statement with the sentence:
‘we believe the purpose of (name of unit/hospital/ward) is to ………………’
Use the information from the common themes mostly from flip chart one. This section
usually consists of three sentences maximum, and relates to what the healthcare team think
are the important attributes of their service or unit.
The second paragraph starts with:
‘we believe this purpose can be achieved by …………….’
This usually consists of the actions that are required to achieve the purpose. Do not use any
information other than that on the post-it notes. You must work only with what you have
and any connecting words that are needed, such as ‘the ‘, ‘and’, ‘if’, ‘with’ etc. Once the first
draft is complete circulate for comments to all staff and residents/families. At this stage, it is
important not to add any extra comments as the first part of the exercise is now complete.
The first draft is circulated for comments.
It is advisable to use eye catching colours and fonts. Try out different styles with colleagues
and residents in the unit/ward for feedback and review as necessary. The vision statement
is ready for implementation when the contents and presentation are agreed by all. A vision
statement for one of the participating sites on the national programme who completed this
exercise is printed with permission below.
‘We believe the purpose of person centred care in St Patrick’s Hospital
is to provide individualised care to patients and their families through
respecting their choices, values, dignity and beliefs. This can be achieved
by ensuring the environment is appropriate to meet the needs of patients,
families and all the staff of St Patrick’s Hospital.
Effective communication and joint decision making between all staff,
patients and their families is the basis of person centred care in St Patrick’s.
We believe the factors that are required to enhance person centred care are
good support mechanisms for staff and encouragement in all aspects of
their development ’
(St Patrick’s Hospital, Carrick-on-Shannon, County Leitrim, 2009)
65

Observation of Care
Information
Guidance for the Healthcare Team
Conducting observations of care within the context of a practice setting provides a method
to extend understanding of the practice area. This process is a learning activity and a vital
part of developing practice and cultures of person-centred care. The healthcare team is
provided with an opportunity to step outside of their usual role of ‘doing’ and observe the
environmental context setting from a different perspective. In many instances familiarity
around the environment and taking for granted daily routines become part of the provision
of care. Carrying out observations of care formally provides an opportunity to look, listen,
hear and review practice in a different way. Observations can begin in a very simple and time
effective way and then build up until they make use of a formal evaluation data collection.
Consideration must be given to the ethical aspects in relation to this exercise.
Seeing practice, raising consciousness about taken for granted practices and assumptions
and reflecting on them are key components of the observations. These activities highlight
the need to see things from a different perspective and to facilitate person-centred care that
can be sustained and thus transform healthcare delivery.
This is a very important learning exercise in which everyone including families/carers can
engage with. In order to undertake this activity a communication process must be carried out
to inform residents, healthcare staff and other key stakeholders of the planned observation.
The process involves a planned approach where documentation is agreed, evaluation,
feedback and action planning mechanisms are established before the observation of care
being carried out.
66
Appendix 5

Guidance on preparation for observation
• Two members of the healthcare team where possible should carry out the observation
which is agreed in the planning stage. It is important that both individuals are familiar
with the process.
• Ensure the information sheet is on display in the place where you intend to carry out
your observation, advising staff and residents of the planned time and date.
• Confirm a day and time when you will carry out the observation.
• Think about when and where you will position yourself.
• About 15 minutes before you plan to start the observation, check with the residents
that they are aware of the proposed activity and ensure that residents give their
consent.
• Inform staff on duty of the planned observation of care.
• Identify a planned time to provide feedback using PD processes and skills.
• Acknowledge and thank all those involved.
67

Information for residents, families and visitors
Members of the healthcare team will soon undertake observations of care. Notices/posters
will be displayed confirming the date and time in advance.
The purpose of this exercise is to review how we organise and deliver care for older people.
We are trying to understand more about what it is like to live here and identify how to
improve the quality of life for residents.
The observation of care will involve two members of staff sitting for a short period, taking
notes about what is going on around them. Findings from this exercise will be used to
improve care, in collaboration with residents.
We would be pleased to answer any questions you may have about the observation of care
activity.
Thank you
..................................................................................
Signed
Programme Participant/ PD group member
68

Observation of Care Template
Name of
Observer
Focus of
Observation
Time Observation Notes
Unit
Date
Observer Comments /
Questions
69

Observation of Care Template - Feedback
(This template was used on the Older Person Service National Practice
Development Programme 2007-2009)
Name of Observer: ..............................................................................................................
Unit: ..............................................................................................................
Focus of Observation: ..............................................................................................................
Date: ..............................................................................................................
Staff present at feedback session ..............................................................................................................
70
Observation Data Observer Comments Observer Feedback
At this stage action areas can be identified following the provision of feedback and an action
plan developed.

Observation of Care Poster for Wards/Units
An Observation of Care
will be carried out in this
ward/unit on:
[ Day and Date ]
[starting and finishing times]
The observers will be
[ ]
Information sheets are
available for patients/
residents and staff
If you have any questions
please ask
[ ]
Thank you
71

72
Appendix 6
Workplace
Culture
Workplace
Critical Culture
Analysis Critical
Tool Analysis
Tool
ORIGINAL AUTHORS OF THE WCCAT
o Brendan McCormack, Professor of Nursing Research University of Ulster and
Director of Nursing Research and Practice development, Royal Hospitals Trust,
Belfast.
o Elizabeth Henderson, Lead Cancer Nurse, Northern Ireland Cancer Network.
o Dr ORIGINAL Val Wilson, AUTHORS Director of OF Nursing THE Research WCCAT & Practice Development, the Children's
o Brendan McCormack, Professor of Nursing Research University of Ulster and
Hospital
Director
at Westmead,
of Nursing
NSW,
Research
Australia.
and Practice development, Royal Hospitals Trust,
o Jayne Belfast. Wright, Research Associate, University of Ulster
o Elizabeth Henderson, Lead Cancer Nurse, Northern Ireland Cancer Network.
o Dr Val Wilson, Director of Nursing Research & Practice Development, the Children's
Hospital at Westmead, NSW, Australia.
o Jayne Wright, Research Associate, University of Ulster
April 2007
Cultural Observation Tool version 5 – March 2007 1
April 2007
The WCCAT has been developed to help people involved in the
development of practice to undertake observational studies of work
place settings in order to inform changes in practice. The tool is
suitable for use by anyone who has some experience of practice
development including the observation of practice. The tool has
been developed from an analysis of our experience of leading and
facilitating practice development programmes over many years.
The WCCAT has been developed to help people involved in the
Observation is one of the key tools used in emancipatory
development of practice to undertake observational studies of work
practice development – a form of practice development that is
place settings in order to inform changes in practice. The tool is
concerned with changing the culture and context of practice in order
suitable for use by anyone who has some experience of practice
to develop sustainable person-centred and evidence-based
development including the observation of practice. The tool has
workplaces. Seeing practice, raising consciousness about taken for
been developed from an analysis of our experience of leading and
granted practices and reflecting on taken for granted assumptions
facilitating practice development programmes over many years.
are key components of comprehensive observation. This tool is
Observation is one of the key tools used in emancipatory
designed to help you develop a systematic approach to undertaking
practice development – a form of practice development that is
these activities.
concerned with changing the culture and context of practice in order
We encourage you to use this tool and would welcome
to develop sustainable person-centred and evidence-based
your feedback on its relevance and usability in your practice
workplaces. Seeing practice, raising consciousness about taken for
development work.
granted practices and reflecting on taken for granted assumptions
Contact
are key components of comprehensive observation. This tool is
Brendan McCormack: bg.mccormack@ulster.ac.uk
designed to help you develop a systematic approach to undertaking
Liz Henderson liz.henderson@bch.n-i.nhs.uk
these activities.
for further information.
We encourage you to use this tool and would welcome
your feedback on its relevance and usability in your practice
development work.
Contact
Brendan McCormack: bg.mccormack@ulster.ac.uk
Liz Henderson liz.henderson@bch.n-i.nhs.uk
for further information.
Cultural Observation Tool version 5 – March 2007 1
72

Introduction and Background
Emancipatory practice development (PD) is a well established methodology that focuses on
changing the culture and context of practice in order to develop sustainable person-centred and
evidence-based workplaces (Manley & McCormack, 2004). In a concept analysis of PD Garbett
& McCormack (2002) articulated the interconnected and synergistic relationships between the
development of knowledge and skills, enablement strategies, facilitation and systematic, rigorous
and continuous processes of emancipatory change in order to achieve the ultimate purpose of
evidence-based person centred care. Manley The & WCCAT McCormack has been (2004) developed articulate to help these people elements involved of in the
PD in a model called ‘emancipatory PD’.
development
Emancipatory
of practice
PD (EPD)
to undertake
recognises,
observational
acknowledges
studies of work
place settings in order to inform changes in practice. The tool is
and works to overcome obstacles and generate new understandings about context and culture and
how to Workplace suitable for use by anyone who has some experience of practice
overcome barriers within them.
development including the observation of practice. The tool has
been developed from an analysis of our experience of leading and
The key elements of emancipatory practice facilitating development practice are: development programmes over many years.
Observation is one of the key tools used in emancipatory
• Working with values, beliefs & assumptions, challenging contradictions
practice development – a form of practice development that is
• Culture
Developing critical intent of individuals concerned & groups with changing the culture and context of practice in order
to develop sustainable person-centred and evidence-based
• Developing moral intent workplaces. Seeing practice, raising consciousness about taken for
• Focusing on the impact of the context
granted
on practice,
practices
as
and
well
reflecting
as practice
on taken
itself
for granted assumptions
are key components of comprehensive observation. This tool is
• Using self-reflection & fostering reflection designed in to others help you develop a systematic approach to undertaking
• Critical
these activities.
Enabling others to ‘see the possibilities’ We encourage you to use this tool and would welcome
• Fostering widening participation & your collaboration feedback by on all its involved relevance and usability in your practice
development work.
• Changing practices
Contact
Brendan McCormack: bg.mccormack@ulster.ac.uk
Facilitating these processes involves cycles of reflective learning and action, so that clinicians:
• Analysis
Liz Henderson liz.henderson@bch.n-i.nhs.uk
Become aware of how they practice & the things
for further
they
information.
take for granted
• Develop an awareness of how the system impacts on the way they work
• Identify the contradictions between what they espouse and what they do
• Challenge the system in which they work to create the potential for better patient care
• Actually change how they practice to reflect individual and collective beliefs and values
• Tool
Continually refine action in light of new understandings gained through reflecting on
practice.
These facilitated processes help clinicians break down barriers to action and enable cultures of
effectiveness to be developed. Key to enabling the development of these cultures is the
observation ORIGINAL of practice. AUTHORS OF THE WCCAT
o Brendan McCormack, Professor of Nursing Research University of Ulster and
Observation Director methods of have Nursing their Research origins in and ‘ethnographic Practice development, research’ methodology. Royal Hospitals Ethnography Trust,
involves the Belfast. researchers entering the area being researched and thus gaining multiple perspectives
in order o to Elizabeth identify links Henderson, with the culture Lead Cancer and thoughts Nurse, and Northern feelings Ireland of the people Cancer at Network. the centre of
the research (Morse1991). The essence of ethnography is to understand another way of life from
the native o Dr point Val of Wilson, view and Director involves of Nursing learning Research from people & Practice (Ersser Development, 1997). It enables the Children's the
observation of taken for granted aspects within health care so that they become visible (Leininger
1995). In
Hospital
a two year
at Westmead,
practice development
NSW, Australia.
programme with nurses from a range of surgical
settings, o Boomer, Jayne Wright, McCormack Research & Henderson Associate, (2006) University found that of helping Ulster participants to develop a
systematic approach to observing practice in their own and in their colleagues’ practice settings
was a key strategy to informing cultural changes. Analysing the processes and outcomes used in
Cultural Observation Tool version 5 – March 2007 2
April 2007
Cultural Observation Tool version 5 – March 2007 1 73
73

74
this project and compared with findings from previous PD programmes of work, resulted in the
development of the WCCAT.
The WCCAT has been informed by a number of theoretical frameworks and development
processes (Table 1):
Framework
The WCCAT
Contribution
has been
to
developed
the WCCAT
to help people involved in the
development of practice to undertake observational studies of work
The Person-Centred Nursing Framework The person-centred nursing theoretical
place settings in order to inform changes in practice. The tool is
(McCormack & McCance 2006)
Workplace suitable framework for use by has anyone identified who has five some care experience processes of practice
development for patient-centred including the care observation and six of attributes practice. of The the tool has
been developed care environment. from an analysis These of care our processes experience and of leading and
facilitating attributes practice have development informed programmes the observation over many foci. years.
Critical Companionship (Titchen 2001) Critical Observation companionship is one of the is key a framework tools used for in emancipatory
practice developing development helping – a form relationships. of practice It development describes that is
Culture
concerned strategies with changing for enabling the culture enlightenment, and context of practice in order
to develop
empowerment
sustainable
and emancipation.
person-centred
In
and
particular
evidence-based
workplaces. Seeing practice, raising consciousness about taken for
the strategies of observing, listening and
granted practices and reflecting on taken for granted assumptions
questioning have informed the facilitation
are key components of comprehensive observation. This tool is
designed strategies to help you in the develop WCCAT. a systematic approach to undertaking
Culture Critical
(Schein 2004) these activities. Schein describes a conceptualisation of culture
that We moves encourage from you superficial to use this to deeper tool and levels would of welcome
your feedback understanding. on its relevance The three and stages usability of analysis in your practice
development outlined work. in the WCCAT are based on this
analysis Contact of culture.
Workplace Culture (Manley 2000 a & b) Manley
Brendan
developed
McCormack:
a set
bg.mccormack@ulster.ac.uk
of staff, patient and
Analysis
Liz Henderson liz.henderson@bch.n-i.nhs.uk
workplace indicators that she suggests need to
for further information.
be in place for an effective person centred and
learning culture. These have been integrated
into the observation foci
Essence of Care (Department of Health Patient Focused Benchmarks for Clinical
[England] Tool 2001)
Governance. Nine fundamental aspects of care
derived from what patients consider important.
Elements of these benchmarks have been
integrated into the observation foci.
Table 1: ORIGINAL Theoretical AUTHORS frameworks OF and THE development WCCAT processes underpinning the WCCAT
o Brendan McCormack, Professor of Nursing Research University of Ulster and
Director of Nursing Research and Practice development, Royal Hospitals Trust,
Belfast.
The use o of these Elizabeth theoretical Henderson, perspectives Lead are Cancer illustrated Nurse, in the Northern conceptual Ireland model Cancer below Network. (Table 2).
This model demonstrates the linkages between the different levels of culture (superficial, middle
and deep) o and Dr how Val the Wilson, phases Director of observation, of Nursing reflection Research and feedback & Practice that Development, underpin the WCCAT the Children's
enable a deep understanding of workplace culture to be achieved and developed in a practice
Hospital at Westmead, NSW, Australia.
development action plan.
o Jayne Wright, Research Associate, University of Ulster
Cultural Observation Tool version 5 – March 2007 3
April 2007
Cultural Observation Tool version 5 – March 2007 1
74

Deeper level - What does it mean
CULTURE LEVELS (AFTER SCHEIN 2004)
Middle level - What is lived
Superficial level - What is seen
Clarifying assumptions through
Workplace
Culture
Consciousness raising and
Critical
Analysis
Tool
ORIGINAL AUTHORS OF THE WCCAT
o Brendan McCormack, Professor of Nursing Research University of Ulster and
Director of Nursing Research and Practice development, Royal Hospitals Trust,
Symbol/artefacts
reflection and critique
Problematisation
Belfast.
o Elizabeth Henderson, Lead Cancer Nurse, Northern Ireland Cancer Network.
o Dr Val Wilson, Director of Nursing Research & Practice Development, the Children's
Hospital at Westmead, NSW, Australia.
o Jayne Wright, Research Associate, University of Ulster
April 2007
Routines
Actions
• Feedback
• Challenge & Support
• Critical dialogue
Interactions
• Observing and listening • Questioning
• Articulation of craft knowledge
FACILITATION
STRATEGIES
(AFTER TTITCHEN
2001)
Observation Areas
Feedback about what has been
observed is offered to clinical teams
using strategies of high challenge and
high support as a catalyst for learning.
The WCCAT has been developed to help people involved in the
development of practice to undertake observational studies of work
place settings in order to inform changes in practice. The tool is
suitable for use by anyone who has some experience of practice
development including the observation of practice. The tool has
been developed from an analysis of our experience of leading and
facilitating practice development programmes over many years.
Observation is one of the key tools used in emancipatory
practice development – a form of practice development that is
concerned with changing the culture and context of practice in order
to develop sustainable person-centred and evidence-based
workplaces. Seeing practice, raising consciousness about taken for
granted practices and reflecting on taken for granted assumptions
are key components of comprehensive observation. This tool is
designed to help you develop a systematic approach to undertaking
these activities.
We encourage you to use this tool and would welcome
your feedback on its relevance and usability in your practice
development work.
Contact
Brendan McCormack: bg.mccormack@ulster.ac.uk
Liz Henderson liz.henderson@bch.n-i.nhs.uk
for further information.
The purpose here is to check out if what has
been observed matches clinicians’ experience,
and in so doing facilitate consciousness raising
and problematisation.
Consciousness-raising is a way of enabling
practitioners become more alert with respect to
daily practice and to their knowledge embedded in
it. The observer poses questions about what has
been observed thus getting clinicians to articulate
their craft knowledge. This helps the clinician to
surface the tacit understandings that have grown
up around repetitive and habitualised practice.
Problematisation is making problematic that
which had previously been assumed to be
satisfactory. It may also refer to the observer
pointing out or questioning things not being
attended to.
The observers adopt the
attributes, reflexivity and skills of
a qualitative researcher, in
observing and listening to
clinicians at work in their every
day working environment.
Observers then engage clinical teams in
critical dialogue with respect to this
feedback.
Using the WCCAT guidelines and
the observation proforma, the
observer systematically records
aspects of practice relevant to the
focus of the observation.
For example,
Physical Environment
Communication
Privacy & Dignity
Patient Involvement
Team Effectiveness
Risk & Safety
Organisation of care
Learning Culture
Critical dialogue promotes collaborative
interpretations, critique and evaluation of
data and validates clinician’ judgment
(where appropriate). This fosters
clinician’s self-awareness, reflective and
critical thinking. Challenging taken-forgranted
assumptions beliefs, values,
expectations, perceptions, judgement and
actions in a constructive, interested,
supportive way helps clinicians gain new
understandings of situations.
NB: these observation
areas may change
according to the
context within which
the WCCAT is used
Cultural Observation Tool version 5 – March 2007 1 75
75
Table 2: WCCAT Conceptual Model
4

Tool
• Discuss the overarching practice development project and the place of cultural analysis in this
work.
• Clarify ethical principles underpinning the processes, such as evidence of ethical approval
ORIGINAL AUTHORS OF THE WCCAT
o Brendan McCormack, Professor of Nursing Research University of Ulster and
Director of Nursing Research and Practice development, Royal Hospitals Trust,
Belfast.
o Elizabeth Henderson, Lead Cancer Nurse, Northern Ireland Cancer Network.
o Dr Val Wilson, Director of Nursing Research & Practice Development, the Children's
Hospital at Westmead, NSW, Australia.
o Jayne Wright, Research Associate, University of Ulster
.
If you do not require formal ethical approval then you should still have evidence of approval
from the management team. Consider also how you will ensure confidentiality, anonymity
and non-interference with ward activities. You will need to secure ‘process consent’, i.e. at
each observation period seek verbal consent from patients and staff for the observations being
undertaken.
• Explain the processes to be used in observation, (e.g. where you will be positioned, number
of observers, number of observations to be undertaken, frequency of observations and the
types of notes you will maintain. Wherever possible, negotiate these arrangements with staff.
• Written information about the study and the procedures should be provided.
• Answer all questions openly and honestly.
April 2007
PROCESS FOR USING THE WCCAT
The WCCAT adopts a five (5) phase process to undertaking an observation study, analysing the data,
feeding back to clinical teams and developing action plans. The five phases are:
The WCCAT has been developed to help people involved in the
development of practice to undertake observational studies of work
place settings in order to inform changes in practice. The tool is
Workplace suitable for use by anyone who has some experience of practice
1. Pre-observation
development including the observation of practice. The tool has
2. Observation
been developed from an analysis of our experience of leading and
3. Consciousness Raising and Problematisation facilitating practice development programmes over many years.
4. Reflection and Critique
Observation is one of the key tools used in emancipatory
practice development – a form of practice development that is
5. Participatory Analysis and Action Planning Culture
concerned with changing the culture and context of practice in order
to develop sustainable person-centred and evidence-based
workplaces. Seeing practice, raising consciousness about taken for
granted practices and reflecting on taken for granted assumptions
are key components of comprehensive observation. This tool is
designed to help you develop a systematic approach to undertaking
Critical
these activities.
Phase 1: Pre observation
We encourage you to use this tool and would welcome
your feedback on its relevance and usability in your practice
Step 1: Preparing the Clinical Area for Observation development work.
Contact
Preparing a clinical area for observation is an important Brendan phase McCormack: of the process. bg.mccormack@ulster.ac.uk
Staff anticipation of
being observed Analysis
can generate heightened anxiety and Liz concern. Henderson It is liz.henderson@bch.n-i.nhs.uk
therefore important to undertake
preparatory work in order to reduce anxiety, clarify for processes further information. to be used and engage staff in planning
for periods of observation.
76
In order to reduce anxiety and prepare for the observation study, it is important to:
[1] Observations of practice that are part of routine practice development projects do not usually require
formal ethical approval from a research ethics committee. In some settings, ‘quality approval’ will be required.
However, should you be intending to develop the practice development work into a research project and/or
publish the findings of your project, then formal ethical approval will be required. Please check the need for
ethical approval with your local ethics committee.
Cultural Observation Tool version 5 – March 2007 1
76
5

As well as negotiating and explaining the observation procedures, it is also important to identify staff
beliefs and values, as a means of identifying the espoused beliefs and values of the team. Values
clarification is a complex and often lengthy process and in this phase it would be impossible to
undertake a values clarification to this extent. However, undertaking a values clarification as a
component of step 1 will enable you to understand the team’s values at a superficial level and provide
a benchmark for considering the data collected during the observations and how this relates to the
values that staff want to underpin their practice. In having this awareness, then feedback can be
structured (phase 4) in a way that is meaningful and less threatening. If the clinical setting does not
have an available set of clarified beliefs and The values WCCAT (such has as a been stated developed philosophy to help of care), people then involved you in the
will need to facilitate a values clarification process development with of team practice members to undertake about their observational practice – studies see of work
appendix 1 for a suggested values clarification place process settings and in also order refer to inform to Manley changes (2000 in practice. a), Wilson The tool is
(2005) or Workplace
Boomer at al (2006) for explanations suitable of the for process. use by anyone who has some experience of practice
development including the observation of practice. The tool has
been developed from an analysis of our experience of leading and
facilitating practice development programmes over many years.
Observation is one of the key tools used in emancipatory
Step 2: Preparing yourself to Observe practice development – a form of practice development that is
Culture
concerned with changing the culture and context of practice in order
In order to systematically gather detailed and to accurate develop information sustainable you person-centred (the observer) and need to evidence-based develop
specific skills in observation including the ability workplaces. to concentrate Seeing practice, in often raising busy consciousness environments, about to stand taken for
granted practices and reflecting on taken for granted assumptions
apart from the context you are observing and to defer any judgements you may wish to make about
are key components of comprehensive observation. This tool is
what you are observing. It is also important for you to take into account the role your own subjectivity
designed to help you develop a systematic approach to undertaking
plays in the observation process (Fawcett Critical
these 1996). activities. Whilst practice helps the observer obtain the
necessary skills, a deeper understanding of the intricacies We encourage of observation you to use is this developed tool and through would such welcome
things as group discussions, self directed learning your feedback and critical on reflection. its relevance and usability in your practice
development work.
The following practical guidelines (adapted from Contact Fawcett 1996) will assist you in preparing and
undertaking an observation using the Critical Analysis Brendan of Workplace McCormack: Culture bg.mccormack@ulster.ac.uk
Tool. The observation is
phase one Analysis
of the critical analysis and relates to what Liz is seen Henderson happening liz.henderson@bch.n-i.nhs.uk
in the clinical setting including
such things as the routines, the actions and interactions. for further The information. findings are used as a basis for critical
discussion with staff about what you have seen and heard, and how this connects to their experience
of practice.
Tool
Guideline Rationale
Preparing for
Observation
(1) What is the It is not possible to observe everything within a multi-sensory environment.
focus of the You need to choose a focus for your observation. You may be required to
observation
ORIGINAL
e.g.
AUTHORS
observe on a
OF
number
THE
of
WCCAT
occasions (at different time periods) to build up a
medication picture of what is happening in a workplace. You need to take into account the
o Brendan McCormack, Professor of Nursing Research University of Ulster and
administration environment, verbal and non verbal communication, actions, events & people
Director of Nursing Research and Practice development, Royal Hospitals Trust,
(2) How will Belfast. you It is helpful to develop a system for documenting your findings that enable
document o your Elizabeth you Henderson, to capture Lead data Cancer during the Nurse, observation Northern in a Ireland timely Cancer manner. Network. Consider what
findings?
o Dr Val Wilson,
abbreviations
Director
or
of
codes
Nursing
you
Research
may use
&
to
Practice
document
Development,
findings. Having
the Children's
large
margins allow you to capture your thoughts during and after the observation.
Hospital at You Westmead, will need NSW, to take Australia. note of things such as place/date/time (see the example
below)
o Jayne Wright, Research Associate, University of Ulster
(3) Gaining access
to the site
(4) Preparing
yourself
April 2007
You need to negotiate access to the site, think about us how often and how
long you might want to observe practice. You also need to inform staff about
the purpose of your observation and obtain consent where appropriate.
It is best to observe with a colleague in order to validate your findings and
agree on key issues. When choosing a partner for observation, consider the
Cultural Observation Tool version 5 – March 2007 6
Cultural Observation Tool version 5 – March 2007 1 77
77

Undertaking an
Observation
(1) Positioning
yourself (+ other
observer if
required)
(2) Time
Workplace
Culture
(3) Recording data
After the
Observation
(1) Review your
notes
(2) Review the
process
Critical
Analysis
(3) Do you require
more observation
Tool
need for an insider/outsider approach (i.e. if you are insider to the setting then
perhaps someone from outside the setting would be most appropriate as a
partner [and vice versa]). Consider having a ‘practice observation’ with a
colleague, that way you can both observe the same thing and then compare
notes about what you observed.
Think where the best advantage point is for you to observe practice. You need
to take into consideration such things as how easy it is for you to observe what
is happening without being The WCCAT ‘in the way’ has been or highly developed visible to help people involved in the
development of practice to undertake observational studies of work
As you are developing place your settings observation in order skills to inform you may changes find that in practice. you can The only tool is
spend 15-20 minutes suitable observing for use practice by anyone at who a time has some as a experience high level of practice of
development including the observation of practice. The tool has
concentration is required. As you become proficient this time can be increased
been developed from an analysis of our experience of leading and
facilitating practice development programmes over many years.
Try to capture as much data as Observation possible. Ensure is one notes of the are key clear tools and used concise. in emancipatory
practice development – a form of practice development that is
concerned with changing the culture and context of practice in order
to develop sustainable person-centred and evidence-based
workplaces. Seeing practice, raising consciousness about taken for
Write any additional granted comments practices as soon and reflecting as possible on taken after for the granted observation assumptions
period as well as any are questions key components you are posing of comprehensive about what you observation. have observed. This tool is
Compare notes with
designed
the other
to
observer
help you develop
to develop
a systematic
a greater
approach
understanding
to undertaking
these activities.
about what was happening.
We encourage you to use this tool and would welcome
your feedback on its relevance and usability in your practice
This can be done as an development individual work. or group activity. What worked well during
the observation? What things Contact could you improve upon? What did you learn
about observation skills and Brendan techniques? McCormack: What impact bg.mccormack@ulster.ac.uk
did your own value
judgements have on what you Liz observed? Henderson It liz.henderson@bch.n-i.nhs.uk
may be helpful to capture your
answers (and future development for further opportunities) information. for your learning portfolio.
Consider whether you (and any other observers) have enough material at this
stage to move onto the next phase. If not you need to consider what the focus
of future observations will be, when it will take place and who will undertake
the observation
(4) Preparing notes
If you feel you have enough material to undertake phase two (consciousness
raising and problematisation) then you need to prepare your observations for
for the next phase feedback to staff and to facilitate a discussion in relation to what you observed
ORIGINAL AUTHORS OF THE WCCAT
o Brendan McCormack, Professor of Nursing Research University of Ulster and
Example of Director Observation of Nursing Record Research and Practice development, Royal Hospitals Trust,
Belfast.
Name of o Observer: Elizabeth Jo Henderson, Smith Lead Cancer Nurse, Northern Unit: Ireland Ward Cancer 4 E Network.
Focus of o Observation: Dr Val Wilson, Communication Director of during Nursing ward Research rounds & Practice Date: 5Development, the Children's
Hospital at Westmead, NSW, Australia.
o Jayne Wright, Research Associate, University of Ulster
April 2007
th August 2006
Time Observation Notes
Observer comments/questions
09.15 Medication round in progress. The nurse approaches Interruptions of nurses during
AS’s bed and checks how the patient’s night has been. medicines rounds seems to be a
Inquires about her pain and uses the pain assessment tool significant issue on this ward. Is
to get an accurate indication of the level of pain. Offers there a relationship between these
analgesia. JRMO approaches nurse as she is getting the interruptions and drug-errors? I
medication from the trolley and questions her re another wonder how the nurses feel about
78
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78

09. 17
patient. JRMO leaves and the nurse appears flustered.
Seems to be unsure what she was doing.
April 2007
these interruptions – are they aware
of them or are they a ‘norm’? This
would be useful to explore in the
feedback session.
Phase 2: Observation
Observation of the workplace culture should The be WCCAT undertaken has been at the developed negotiated to help time people by two involved trained in the
observers using the WCCAT observation proforma. development Who of practice the observers to undertake are may observational be different studies in each of work
project in which the WCCAT is being used place and settings may include in order different to inform combinations changes in practice. of internal The and tool is
external Workplace
observers. Observers should maintain suitable field for use notes by about anyone the who experience has some experience as a process of practice for
development including the observation of practice. The tool has
reviewing the effectiveness of the observation undertaken.
been developed from an analysis of our experience of leading and
facilitating practice development programmes over many years.
Observation is one of the key tools used in emancipatory
Phase 3. Consciousness Raising and Problematisation
practice development – a form of practice development that is
When the Culture
observation is finished you (the concerned observers) with should changing firstly the culture clarify and with context individual of practice team in order
members anything you are unsure of. You to should develop also sustainable discuss with person-centred staff specific and aspects evidence-based of the
observation data that you want to further clarify workplaces. or gain Seeing a deeper practice, understanding raising consciousness of. Start about by asking taken for
them open questions relevant to each of the granted eight observation practices and areas reflecting in turn on as taken outlined for in granted the WCCAT assumptions
proforma. This will help you gain insight are into key the components practice context of comprehensive and minimise observation. the risk This of you tool is
making false assumptions about what you saw. designed You to should help you use develop questions a systematic such as approach ‘what is to it undertaking like to
Critical
these activities.
work in this environment?’ how effective is communication here? How is care organised here? Tell
We encourage you to use this tool and would welcome
me about how learning takes place here etc. You should make notes/record all responses.
your feedback on its relevance and usability in your practice
development work.
Contact
Phase 4: Reflection and Critique
Brendan McCormack: bg.mccormack@ulster.ac.uk
Both observers Analysis
compare their observations and agree Liz a Henderson common set liz.henderson@bch.n-i.nhs.uk
of issues to feedback to the ward
team. During the feedback session, a critical dialogue for is further facilitated information. by the observers with staff. This is
done by the observers presenting their ‘common issues’ as impressions only and putting them up to
challenge by staff. Each observation area is discussed in this way and the discussion includes the
comparing of the issues raised with the espoused philosophy/values and beliefs/empirical evidence.
By the end of the critical dialogue a common set of issues is agreed between clinical staff and the
observers Tool and these issues form the basis of:
1. Further investigation into specific areas using focused observation instruments, such as Nursing
Handover/Mealtimes/Privacy & Dignity or Audit of specific aspects of practice, for example
Infection Control, Care Records etc.
2. Formulation of a practice development action plan.
3. Development ORIGINAL of a AUTHORS staff development OF THE action WCCAT plan.
o Brendan McCormack, Professor of Nursing Research University of Ulster and
Process for Director engaging of in Nursing the critical Research dialogue and session Practice development, Royal Hospitals Trust,
Belfast.
To avoid interruption and to enable the critical discussion to take place, observers/facilitators and
members
o
of
Elizabeth
the clinical
Henderson,
team, at an
Lead
agreed
Cancer
time, should
Nurse,
move
Northern
to an appropriate
Ireland Cancer
quiet
Network.
area. Facilitators
should reiterate o Dr Val the Wilson, purpose of Director this session, of Nursing which is Research to collectively & Practice make Development, sense of what has the been Children's both
observed and articulated with a view to the clinical team agreeing the areas of practice that need
either further Hospital exploration at Westmead, or development. NSW, Staff Australia. may be feeling apprehensive, so it is important to set
a positive tone in terms of acknowledging their contribution to the process thus far. It may be helpful
o Jayne Wright, Research Associate, University of Ulster
at this stage to establish ground rules for the session to enable dialogue. It is important that
facilitators do not appear to be ‘sitting in judgment’ on the ward team, but rather are offering their
observations for critical reflection and discussion to enable insight and learning. The Critical
Companion Relationship Domain supports the need for facilitators to ‘work with’ the ward team
demonstrating ‘graceful care’ in a collaborative spirit of ‘giving and receiving’.
Cultural Observation Tool version 5 – March 2007 8
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79

80
One method of feeding back may be to offer some general feedback first (using the ‘praise sandwich’
technique - positive first, then the less positive, and finishing with positive again), then actively
engage with staff by focusing on a number of specific areas for more in-depth exploration. In this
exercise observers/facilitators are attempting to challenge practice by drawing attention to the
differences between values espoused and those observed in practice in order to enable staff to see
things from a different perspective. For example:
“Your philosophy states you aim to provide patient centred care yet in practice we have
observed that getting the task done The seems WCCAT to be has more been important developed than to help stopping people to involved listen to in the
patients, what might be going on here? development How does of practice that observation to undertake make observational you feel? studies What of is work
being valued here? Why is that? What place is settings that saying in order about to inform the culture changes you in work practice. in? What The tool is
Workplace
would person-centredness look like? suitable What for might use by be anyone hindering who the has team some from experience being able of to practice
undertake that? What would
development
help the
including
team to provide
the observation
care in that
of practice.
way?
The tool has
been developed from an analysis of our experience of leading and
facilitating practice development programmes over many years.
Processes used for example in action learning sets should
Observation
be employed,
is one of the
such
key
as
tools
attending
used in
and
emancipatory
active
listening, one person speaking at a time, practice open development questioning, – a probing, form of practice reflecting development back, non- that is
confrontational Culture
challenging and using positive concerned affirmation with changing to give support. the culture To and achieve context closure of practice it may in order
be helpful to evaluate the critical dialogue to session develop in terms sustainable of what person-centred they found most and useful, evidence-based least
useful and one thing they are taking away that workplaces. they have Seeing learnt. practice, raising consciousness about taken for
granted practices and reflecting on taken for granted assumptions
are key components of comprehensive observation. This tool is
Phase 5: Participatory Analysis and Action designed Planning to help you develop a systematic approach to undertaking
Once you Critical
have the information from phases
these
2-5,
activities.
the next stage is to make some sense of it and try and
We encourage you to use this tool and would welcome
understand what it is telling you and staff on the ward. The process for doing this is to theme the
your feedback on its relevance and usability in your practice
data.
development work.
Contact
The data analysis phase should be undertaken as Brendan a participatory McCormack: analysis bg.mccormack@ulster.ac.uk
with the ward staff. As
many of Analysis
the ward staff as possible, or a representative Liz Henderson sample liz.henderson@bch.n-i.nhs.uk
of staff should participate in the
analysis of the data (It is essential that the Ward for Sister/Charge further information. Nurse/Nursing Unit Manager are
included). Themes for action planning are arrived at by going back and forth between the different
data sets and identifying similarities and differences. Participants in the data analysis are asked to
identify impressions, feelings, metaphors, key words and images that reflect the data. This process
helps to develop an intimate knowledge of the data and an ‘embodiment’ of it, i.e. how the data feels.
Initial impressions Tool are noted and a list of tentative themes and common issues are noted. The themes
are then revised and refined and narrative or examples of what was observed are selected to link the
themes. Theme statements are then written based on common characteristics. All findings are
compared for patterns, commonalities, differences and unique happenings. A six-step process
adapted from McCormack (2002) is set out below. Participants in the data analysis process should
undertake ORIGINAL steps 1-5 independently AUTHORS of OF each THE other WCCAT and step 6 should be undertaken together:
o Brendan McCormack, Professor of Nursing Research University of Ulster and
1. Look at Director all the information of Nursing you Research have and and read Practice it though development, a few times. A Royal few things Hospitals may stick Trust, out
in your Belfast. mind such as something that happened more then once or something that you thought was
really o good Elizabeth or concerned Henderson, you. Lead Cancer Nurse, Northern Ireland Cancer Network.
2. Devise an ‘image’ (could be a collage, a poem, a collection of metaphors, movements etc) that
captures o Dr the Val ‘essence’ Wilson, of Director the data overall of Nursing for you. Research Each participant & Practice does Development, this and shares the their Children's
image with other participants. This stage helps to ground the holistic nature of the data and
Hospital at Westmead, NSW, Australia.
provides a tangible representation of the whole data set before the next stages occur and during
which o the Jayne data Wright, will be segmented. Research Associate, University of Ulster
3. Return to the data and as you are reading it through, think about how the data is linked, for
example you may have noted that a person was given choice about when they wanted to get up
and that the nurse took time to listen and follow the persons wishes. Another time a nurse, asked a
person where they would like to sit in the lounge and gave the person time to make their decision.
You could theme this as ‘Patient choice’ or ‘Respect for the individual’. Another example may be
that screening was inappropriate around a person’s bed and it was noted by the observer that they
could
April
see
2007
behind the curtains whilst the patient was having personal care. Another time a nurse
Cultural Observation Tool version 5 – March 2007 9
Cultural Observation Tool version 5 – March 2007 1
80

walked behind the curtain without asking. These you can theme as ‘lack of privacy or ‘lack of
respect for the individual’.
4. Go through all the data developing the themes and keeping in mind your ‘image’ which is a
representation of the essences of the whole data set. Consider the linkages between the themes
you are developing and the image. Do the themes help to add detail to the whole image? Is there
a relationship between the image and the individual themes? Are some themes stronger than
others?
5. Refine the themes. Each participant in the workshop shares their initial themes and any
explanations that might help make sense The of the WCCAT themes has for been others. developed Do not to worry help people if you have involved lots in the
of themes at first, by reading and reviewing development the themes of practice these will to undertake become less. observational The themes studies are of work
then synthesised/reduced by using postit place notes. settings Firstly in the order themes to inform are written changes on in flipchart practice. paper. The tool is
Each Workplace
person, using postit notes suggests suitable where there for use are by overlaps, anyone who shared has meanings some experience and areas of of practice
commonality. It is easy to think that some
development
things are
including
obvious
the
and
observation
do not need
of
including
practice.
but
The tool has
been developed from an analysis of our experience of leading and
remember that it is this everyday taken-for-granted information/data that is important.
facilitating practice development programmes over many years.
6. Once you have some tentative shared themes discuss
Observation
them in
is
the
one
group
of the
and
key
agree
tools used
that these
in emancipatory
are
shared themes. Identify the individual data practice sources development that are linked – a form to these of practice themes development and note them. that is
Culture
concerned with changing the culture and context of practice in order
You now have your list of themes and can go to on develop and develop sustainable the action person-centred plan. and evidence-based
workplaces. Seeing practice, raising consciousness about taken for
Process for Devising Action Plans granted practices and reflecting on taken for granted assumptions
When you have a finalised list of themes, plan are an key action components planning of workshop comprehensive with the observation. ward This tool is
sister/charge nurse/nursing unit manager and designed the staff to of help the you ward develop (as many a systematic as possible approach to attend to undertaking or a
representative Critical
sample of staff, but it essential
these
that
activities.
the Ward Sister/Charge Nurse/Nursing Unit
We encourage you to use this tool and would welcome
Manager is included) to develop an action plan.
your feedback on its relevance and usability in your practice
development work.
Each theme should be considered as an area for action. Contact However, some themes may be combined and
actions developed to address the combined themes. Brendan Alternatively McCormack: you may bg.mccormack@ulster.ac.uk
find that an identified
action(s) Analysis
may address a number of themes. Whatever Liz way Henderson you structure liz.henderson@bch.n-i.nhs.uk
it, you action plan should
include:
for further information.
1. Focus of the action (the theme)
2. The specific actions being taken, i.e. state “set up weekly team meetings” as opposed to
“establish better communication in the team”.
3. Consider any policies in the organisation that need to be considered/implemented/adhered to.
4. Tool
Identify the person(s) responsible for taking the action.
5. Agree achievement dates
6. Agree review dates
7. Have the action plan approved by the relevant line manager
Congratulations, ORIGINAL you AUTHORS have completed OF THE the full WCCAT observation cycle.
o Brendan McCormack, Professor of Nursing Research University of Ulster and
Director of Nursing Research and Practice development, Royal Hospitals Trust,
Belfast.
o Elizabeth Henderson, Lead Cancer Nurse, Northern Ireland Cancer Network.
o Dr Val Wilson, Director of Nursing Research & Practice Development, the Children's
Hospital at Westmead, NSW, Australia.
o Jayne Wright, Research Associate, University of Ulster
April 2007
Cultural Observation Tool version 5 – March 2007 10
Cultural Observation Tool version 5 – March 2007 1 81
81

Cultural Observation Tool – version 4 11
82
Workplace
Culture
Critical
Analysis
Tool
ORIGINAL AUTHORS OF THE WCCAT
o Brendan McCormack, Professor of Nursing Research University of Ulster and
Director of Nursing Research and Practice development, Royal Hospitals Trust,
Belfast.
o Elizabeth Henderson, Lead Cancer Nurse, Northern Ireland Cancer Network.
o Dr Val Wilson, Director of Nursing Research & Practice Development, the Children's
Hospital at Westmead, NSW, Australia.
o Jayne Wright, Research Associate, University of Ulster
April 2007
Observer Prompts Observation Notes Questions Arising
• What impression do you get from looking at the
setting? (You should consider various areas within
the ward/department, for example patient rooms,
nurses station etc)
• What do you see, hear and smell (consider noise
levels, lighting, dominating smells and activities
that appear to shape the culture)
• Are call bells answered promptly?
• Who does the environment privilege? Consider
how patient friendly it is, or how staff friendly it
is? Are there forbidden patient areas? Is there
adequate seating for visitors etc?)
• How is space used / furniture arranged / layout?
(For example are chairs placed convenient and
ready for use when staff are communicating with
patients; also consider equipment location. Is the
space cluttered? Are lockers and bedside tables
clean and tidy? Is there space for visitors to sit and
be with the patient?)
• Who takes responsibility for the environment?
The WCCAT has been developed to help people involved in the
development of practice to undertake observational studies of work
place settings in order to inform changes in practice. The tool is
suitable for use by anyone who has some experience of practice
development including the observation of practice. The tool has
been developed from an analysis of our experience of leading and
facilitating practice development programmes over many years.
Observation is one of the key tools used in emancipatory
practice development – a form of practice development that is
concerned with changing the culture and context of practice in order
to develop sustainable person-centred and evidence-based
workplaces. Seeing practice, raising consciousness about taken for
granted practices and reflecting on taken for granted assumptions
are key components of comprehensive observation. This tool is
designed to help you develop a systematic approach to undertaking
these activities.
We encourage you to use this tool and would welcome
your feedback on its relevance and usability in your practice
development work.
Contact
Brendan McCormack: bg.mccormack@ulster.ac.uk
Liz Henderson liz.henderson@bch.n-i.nhs.uk
for further information.
Cultural Observation Tool version 5 – March 2007 1
82
Observation Area 1: Physical Environment
Workplace Culture Observation Proforma

Observation Area 2: COMMUNICATION
Observer Prompts Observation Notes Questions Arising
• When and where does communication take
place?
• Who communicates with whom? (Include staffpatient,
staff-staff etc identifying professional
type)
Workplace
Culture
Critical
Analysis
Tool
ORIGINAL AUTHORS OF THE WCCAT
o Brendan McCormack, Professor of Nursing Research University of Ulster and
Director of Nursing Research and Practice development, Royal Hospitals Trust,
Belfast.
o Elizabeth Henderson, Lead Cancer Nurse, Northern Ireland Cancer Network.
o Dr Val Wilson, Director of Nursing Research & Practice Development, the Children's
Hospital at Westmead, NSW, Australia.
o Jayne Wright, Research Associate, University of Ulster
April 2007
The WCCAT has been developed to help people involved in the
development of practice to undertake observational studies of work
place settings in order to inform changes in practice. The tool is
suitable for use by anyone who has some experience of practice
development including the observation of practice. The tool has
been developed from an analysis of our experience of leading and
facilitating practice development programmes over many years.
Observation is one of the key tools used in emancipatory
practice development – a form of practice development that is
concerned with changing the culture and context of practice in order
to develop sustainable person-centred and evidence-based
workplaces. Seeing practice, raising consciousness about taken for
granted practices and reflecting on taken for granted assumptions
are key components of comprehensive observation. This tool is
designed to help you develop a systematic approach to undertaking
these activities.
We encourage you to use this tool and would welcome
your feedback on its relevance and usability in your practice
development work.
Contact
Brendan McCormack: bg.mccormack@ulster.ac.uk
Liz Henderson liz.henderson@bch.n-i.nhs.uk
for further information.
• How effective is nursing hand-over? (Pay
attention to the quality and type of information
handed over, as well as to the focus of the
report, its location etc)
• What type of language is used? (This refers to
staff communicating generally as well as
during nursing hand-over, is the language
used patient centred, biomedical, or industrial
type language more associated with production
lines?)
• How are patients talked about? (Include all
professionals – see note above)
• How do staff refer to each other? (Include all
professionals – with respect/distain etc?)
• How do staff engage with each other?
(consider tone of voice, pace, pitch of voice;
consider how different staff participate/don’t
participate in ward rounds)
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83
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Cultural Observation Tool – version 4 13
84
Workplace
Culture
Critical
Analysis
Tool
ORIGINAL AUTHORS OF THE WCCAT
o Brendan McCormack, Professor of Nursing Research University of Ulster and
Director of Nursing Research and Practice development, Royal Hospitals Trust,
Belfast.
o Elizabeth Henderson, Lead Cancer Nurse, Northern Ireland Cancer Network.
o Dr Val Wilson, Director of Nursing Research & Practice Development, the Children's
Hospital at Westmead, NSW, Australia.
o Jayne Wright, Research Associate, University of Ulster
April 2007
What importance is placed on the tools of
communication? (Here you should consider the
attention that is paid to the various communication
means)
Is confidentiality respected?
Do staff have meaningful engagement with
patients or fleeting/task oriented conversations?
written documentation, computers, whiteboards
etc)
What messages does staff body language convey?
(Between staff, between staff and patients)
Are visitors made to feel welcome? (how Are they
greeted and treated?)
What tools are used to enable communication?
(Here you should note the various systems in use,
The WCCAT has been developed to help people involved in the
development of practice to undertake observational studies of work
place settings in order to inform changes in practice. The tool is
suitable for use by anyone who has some experience of practice
development including the observation of practice. The tool has
been developed from an analysis of our experience of leading and
facilitating practice development programmes over many years.
Observation is one of the key tools used in emancipatory
practice development – a form of practice development that is
concerned with changing the culture and context of practice in order
to develop sustainable person-centred and evidence-based
workplaces. Seeing practice, raising consciousness about taken for
granted practices and reflecting on taken for granted assumptions
are key components of comprehensive observation. This tool is
designed to help you develop a systematic approach to undertaking
these activities.
We encourage you to use this tool and would welcome
your feedback on its relevance and usability in your practice
development work.
Contact
Brendan McCormack: bg.mccormack@ulster.ac.uk
Liz Henderson liz.henderson@bch.n-i.nhs.uk
for further information.
Cultural Observation Tool version 5 – March 2007 1
84

Observation Area 3: PRIVACY & DIGNITY
Observer Prompts Observation Notes Questions Arising
• Is patient privacy respected during specific
procedures?
• How is the valuing of diversity
demonstrated (including attitudes and
behaviour towards minority groups, e.g.
black and minority ethnic communities)?
• Are individuals needs and choices
ascertained and continuously reviewed?
• How is the acceptability of personal contact
(touch) identified with individual patients
/clients?
• How are the patient’s /client’s personal
boundaries identified and respected and
communicated to others?
• How is clinical risk handled in relation to
complete privacy?
• Note how privacy is effectively maintained
e.g. curtains, screens, walls, rooms, use of
blankets, appropriate clothing, appropriate
positioning of patient etc
• Note how privacy is achieved at times
when the presence of others is required
• Note how modesty is achieved for those in
transit to differing care environments
• How are patients/clients views and needs
ascertained and recorded?
• Is information adapted to meet the needs of
individual patients?
Workplace
Culture
Critical
Analysis
Tool
ORIGINAL AUTHORS OF THE WCCAT
o Brendan McCormack, Professor of Nursing Research University of Ulster and
Director of Nursing Research and Practice development, Royal Hospitals Trust,
Belfast.
o Elizabeth Henderson, Lead Cancer Nurse, Northern Ireland Cancer Network.
o Dr Val Wilson, Director of Nursing Research & Practice Development, the Children's
Hospital at Westmead, NSW, Australia.
o Jayne Wright, Research Associate, University of Ulster
April 2007
The WCCAT has been developed to help people involved in the
development of practice to undertake observational studies of work
place settings in order to inform changes in practice. The tool is
suitable for use by anyone who has some experience of practice
development including the observation of practice. The tool has
been developed from an analysis of our experience of leading and
facilitating practice development programmes over many years.
Observation is one of the key tools used in emancipatory
practice development – a form of practice development that is
concerned with changing the culture and context of practice in order
to develop sustainable person-centred and evidence-based
workplaces. Seeing practice, raising consciousness about taken for
granted practices and reflecting on taken for granted assumptions
are key components of comprehensive observation. This tool is
designed to help you develop a systematic approach to undertaking
these activities.
We encourage you to use this tool and would welcome
your feedback on its relevance and usability in your practice
development work.
Contact
Brendan McCormack: bg.mccormack@ulster.ac.uk
Liz Henderson liz.henderson@bch.n-i.nhs.uk
for further information.
Cultural Observation Tool version 5 – March 2007 1 85
85
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Cultural Observation Tool – version 4 15
86
Workplace
Culture
Critical
Analysis
Tool
ORIGINAL AUTHORS OF THE WCCAT
o Brendan McCormack, Professor of Nursing Research University of Ulster and
Director of Nursing Research and Practice development, Royal Hospitals Trust,
Belfast.
o Elizabeth Henderson, Lead Cancer Nurse, Northern Ireland Cancer Network.
o Dr Val Wilson, Director of Nursing Research & Practice Development, the Children's
Hospital at Westmead, NSW, Australia.
o Jayne Wright, Research Associate, University of Ulster
April 2007
• Do staff involve patients in planning and
evaluating their care?
• Do staff involve patients in making plans
for their discharge from hospital?
• Do staff have a rapport with patients?
• (General easy communication )
• Is there evidence of staff developing
meaningful relationships with patients?
• (Note with whom)
• Is there evidence of patient education
occurring as a part of everyday practice?
• Is there evidence of patients being able to
make choices?
Observation Area 4: PATIENT INVOLVEMENT
Observer Prompts Observation Notes Questions Arising
The WCCAT has been developed to help people involved in the
development of practice to undertake observational studies of work
place settings in order to inform changes in practice. The tool is
suitable for use by anyone who has some experience of practice
development including the observation of practice. The tool has
been developed from an analysis of our experience of leading and
facilitating practice development programmes over many years.
Observation is one of the key tools used in emancipatory
practice development – a form of practice development that is
concerned with changing the culture and context of practice in order
to develop sustainable person-centred and evidence-based
workplaces. Seeing practice, raising consciousness about taken for
granted practices and reflecting on taken for granted assumptions
are key components of comprehensive observation. This tool is
designed to help you develop a systematic approach to undertaking
these activities.
We encourage you to use this tool and would welcome
your feedback on its relevance and usability in your practice
development work.
Contact
Brendan McCormack: bg.mccormack@ulster.ac.uk
Liz Henderson liz.henderson@bch.n-i.nhs.uk
for further information.
Cultural Observation Tool version 5 – March 2007 1
86

Observation Area 5: TEAM EFFECTIVENESS
Observer Prompts Observation Notes Questions Arising
• Do different staff groups have respect for
each other?
• Do staff work as a team?
• Is there evidence of a hierarchy between
and among staff?
• Do staff have a clear sense of purpose?
• Do staff freely question, challenge and
support each other?
• Is there evidence of staff initiating changes
in practice?
• Is decision making transparent,
participative and democratic?
• What style of leadership is in evidence?
• Do the staffing levels seem appropriate to
the workload in order to deliver quality
patient care?
• Is the skill-mix appropriate?
• Is there praise and recognition for a job
well done?
Workplace
Culture
Critical
Analysis
Tool
ORIGINAL AUTHORS OF THE WCCAT
o Brendan McCormack, Professor of Nursing Research University of Ulster and
Director of Nursing Research and Practice development, Royal Hospitals Trust,
Belfast.
o Elizabeth Henderson, Lead Cancer Nurse, Northern Ireland Cancer Network.
o Dr Val Wilson, Director of Nursing Research & Practice Development, the Children's
Hospital at Westmead, NSW, Australia.
o Jayne Wright, Research Associate, University of Ulster
April 2007
The WCCAT has been developed to help people involved in the
development of practice to undertake observational studies of work
place settings in order to inform changes in practice. The tool is
suitable for use by anyone who has some experience of practice
development including the observation of practice. The tool has
been developed from an analysis of our experience of leading and
facilitating practice development programmes over many years.
Observation is one of the key tools used in emancipatory
practice development – a form of practice development that is
concerned with changing the culture and context of practice in order
to develop sustainable person-centred and evidence-based
workplaces. Seeing practice, raising consciousness about taken for
granted practices and reflecting on taken for granted assumptions
are key components of comprehensive observation. This tool is
designed to help you develop a systematic approach to undertaking
these activities.
We encourage you to use this tool and would welcome
your feedback on its relevance and usability in your practice
development work.
Contact
Brendan McCormack: bg.mccormack@ulster.ac.uk
Liz Henderson liz.henderson@bch.n-i.nhs.uk
for further information.
Cultural Observation Tool version 5 – March 2007 1 87
87
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Cultural Observation Tool – version 4 17
88
• Are opportunities for learning maximised?
(For example at hand-over or through
reflective conversations during daily
activity etc)
• Is there evidence of a staff performance
development/appraisal system in place?
• Are policy and practice guidelines used to
inform practice decisions?
• Are there mechanism for formal learning?
(Study leave, induction programmes,
mentorship, etc)
• What kind of learning is privileged – e.g.
technical skills or holistic practice
knowledge?
• Is there evidence of critical reflection
happening (consider evidence of critical
questioning between staff; action learning,
critical companionship; clinical
supervision; workplace coaching).
• Do staff engage patients/families in
learning about their illness/health and
social care needs and approaches to self or
assisted care?
Workplace
Culture
Critical
Analysis
Tool
ORIGINAL AUTHORS OF THE WCCAT
o Brendan McCormack, Professor of Nursing Research University of Ulster and
Director of Nursing Research and Practice development, Royal Hospitals Trust,
Belfast.
o Elizabeth Henderson, Lead Cancer Nurse, Northern Ireland Cancer Network.
o Dr Val Wilson, Director of Nursing Research & Practice Development, the Children's
Hospital at Westmead, NSW, Australia.
o Jayne Wright, Research Associate, University of Ulster
April 2007
having access to computer, books, journals
etc)
• Is there evidence of resources for learning
being available (consider evidence of staff
Observation Area 6: LEARNING CULTURE
Observer Prompts Observation Notes Questions Arising
The WCCAT has been developed to help people involved in the
development of practice to undertake observational studies of work
place settings in order to inform changes in practice. The tool is
suitable for use by anyone who has some experience of practice
development including the observation of practice. The tool has
been developed from an analysis of our experience of leading and
facilitating practice development programmes over many years.
Observation is one of the key tools used in emancipatory
practice development – a form of practice development that is
concerned with changing the culture and context of practice in order
to develop sustainable person-centred and evidence-based
workplaces. Seeing practice, raising consciousness about taken for
granted practices and reflecting on taken for granted assumptions
are key components of comprehensive observation. This tool is
designed to help you develop a systematic approach to undertaking
these activities.
We encourage you to use this tool and would welcome
your feedback on its relevance and usability in your practice
development work.
Contact
Brendan McCormack: bg.mccormack@ulster.ac.uk
Liz Henderson liz.henderson@bch.n-i.nhs.uk
for further information.
Cultural Observation Tool version 5 – March 2007 1
88

Observation Area 7: RISK AND SAFETY
Observer Prompts Observation Notes Questions Arising
Workplace
Culture
Critical
Analysis
Tool
• Is equipment, used, maintained and
monitored appropriately?
• Are patients able to gain staff attention
when needed? (buzzers being attended to
etc)
• Are assessments of risk used and acted
upon?
• Are the levels of risk taken appropriate to
the practice context?
• Is hand washing consistent with accepted
standards?
• Are open medicine trolleys left unattended?
• Do staff check patients’ armbands when
administering medicines?
• Are appropriate procedures for the
handling and removal of used laundry in
place?
• Are bathroom areas maintained
appropriately?
• Is the environment free from risk?
ORIGINAL AUTHORS OF THE WCCAT
o Brendan McCormack, Professor of Nursing Research University of Ulster and
Director of Nursing Research and Practice development, Royal Hospitals Trust,
Belfast.
o Elizabeth Henderson, Lead Cancer Nurse, Northern Ireland Cancer Network.
o Dr Val Wilson, Director of Nursing Research & Practice Development, the Children's
Hospital at Westmead, NSW, Australia.
o Jayne Wright, Research Associate, University of Ulster
April 2007
The WCCAT has been developed to help people involved in the
development of practice to undertake observational studies of work
place settings in order to inform changes in practice. The tool is
suitable for use by anyone who has some experience of practice
development including the observation of practice. The tool has
been developed from an analysis of our experience of leading and
facilitating practice development programmes over many years.
Observation is one of the key tools used in emancipatory
practice development – a form of practice development that is
concerned with changing the culture and context of practice in order
to develop sustainable person-centred and evidence-based
workplaces. Seeing practice, raising consciousness about taken for
granted practices and reflecting on taken for granted assumptions
are key components of comprehensive observation. This tool is
designed to help you develop a systematic approach to undertaking
these activities.
We encourage you to use this tool and would welcome
your feedback on its relevance and usability in your practice
development work.
Contact
Brendan McCormack: bg.mccormack@ulster.ac.uk
Liz Henderson liz.henderson@bch.n-i.nhs.uk
for further information.
Cultural Observation Tool version 5 – March 2007 1 89
89
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Cultural Observation Tool – version 4 19
90
Workplace
Culture
Critical
Analysis
Tool
ORIGINAL AUTHORS OF THE WCCAT
o Brendan McCormack, Professor of Nursing Research University of Ulster and
Director of Nursing Research and Practice development, Royal Hospitals Trust,
Belfast.
o Elizabeth Henderson, Lead Cancer Nurse, Northern Ireland Cancer Network.
o Dr Val Wilson, Director of Nursing Research & Practice Development, the Children's
Hospital at Westmead, NSW, Australia.
o Jayne Wright, Research Associate, University of Ulster
April 2007
• Is care delivered consistently ? (Here you
should check if nurses, irrespective of
what shift, deliver care consistently to
individual patients, for example by
paying attention to the care plan etc)
• Are nurses visible in patient areas?
• Do nurses demonstrate responsibility for
practice? (here you are looking to see
follow through, active communication,
checking mechanisms etc)
• Are meal times given priority?
• Are patients who need help with eating
and drinking given the appropriate help?
• Is off duty planned around the needs of
patients?
• Are patients content with visiting
arrangements?
consistent with the method of organising
care?
Observation area 8: ORGANISATION OF CARE
Observer Prompts Observation Notes Questions Arising
• Is the organisation of care patient
centred?
• Do patients have an individualised plan
of care (including discharge plan)?
• Do nurses demonstrate care for patients?
Make note of how they do (or do not)
• Is the system of nursing hand-over
The WCCAT has been developed to help people involved in the
development of practice to undertake observational studies of work
place settings in order to inform changes in practice. The tool is
suitable for use by anyone who has some experience of practice
development including the observation of practice. The tool has
been developed from an analysis of our experience of leading and
facilitating practice development programmes over many years.
Observation is one of the key tools used in emancipatory
practice development – a form of practice development that is
concerned with changing the culture and context of practice in order
to develop sustainable person-centred and evidence-based
workplaces. Seeing practice, raising consciousness about taken for
granted practices and reflecting on taken for granted assumptions
are key components of comprehensive observation. This tool is
designed to help you develop a systematic approach to undertaking
these activities.
We encourage you to use this tool and would welcome
your feedback on its relevance and usability in your practice
development work.
Contact
Brendan McCormack: bg.mccormack@ulster.ac.uk
Liz Henderson liz.henderson@bch.n-i.nhs.uk
for further information.
Cultural Observation Tool version 5 – March 2007 1
90

References
Boomer C, McCormack B and Henderson E (2006) Development of leadership and
practice development knowledge and skills with ward sisters in surgical settings in the
Royal Hospitals and Belfast City Hospital. Final Report, Royal Hospitals Trust,
Belfast.
Department of Health (2001) Essence of Care: Patient Focused Benchmarks for
Clinical Governance (DoH 2001).
Workplace
Culture
Critical
Analysis
The WCCAT has been developed to help people involved in the
development of practice to undertake observational studies of work
place settings in order to inform changes in practice. The tool is
Esser S J (1997) Nursing as a therapeutic activity; ethnography. Aldershot Avebury
publishers, UK.
suitable for use by anyone who has some experience of practice
development including the observation of practice. The tool has
been developed from an analysis of our experience of leading and
facilitating practice development programmes over many years.
Observation is one of the key tools used in emancipatory
Fawcett M (1996) Learning through child observation. Jessica Kingsley, London.
practice development – a form of practice development that is
Garbett R. & McCormack B. (2002): A concept analysis of practice development. NT
Research 7, 2, 87-100.
concerned with changing the culture and context of practice in order
to develop sustainable person-centred and evidence-based
workplaces. Seeing practice, raising consciousness about taken for
Leininger M M(1985) Qualitative Research Methods in Nursing. Grune and Stratton.,
London.
granted practices and reflecting on taken for granted assumptions
are key components of comprehensive observation. This tool is
designed to help you develop a systematic approach to undertaking
these activities.
We encourage you to use this tool and would welcome
your feedback on its relevance and usability in your practice
development work.
Contact
Brendan McCormack: bg.mccormack@ulster.ac.uk
Liz Henderson liz.henderson@bch.n-i.nhs.uk
for further information.
Manley K. (2000a) Organisational culture and consultant nurse outcomes: part 1 --
organisational culture... first published in Nursing Standard; 14:34-38, including
commentary by Scholes J. Nursing in Critical Care. 5, 4, 179-86.
Manley K. (2000b) Organisational culture and consultant nurse outcomes: part 2 --
consultant nurse outcomes... including commentary by Scholes J. Nursing in Critical
Care. 5, 5, 240-8.
Manley K and McCormack B (2004) Practice Development: purpose, methodology,
facilitation and evaluation in McCormack B; Manley K and Garbett R (2004)
Practice Tool Development in Nursing. Blackwell Publishing, Oxford.
Morse J M(1991) Qualitative Nursing Research: A contemporary dialogue. Sage,
London.
ORIGINAL AUTHORS OF THE WCCAT
McCormack
o Brendan
B and
McCormack,
McCance T (2006)
Professor
Development
of Nursing
of
Research
a framework
University
for person-
of Ulster and
centred nursing.
Director
Journal
of Nursing
of Advanced
Research
Nursing,
and Practice
56(5):
development,
1-8.
Royal Hospitals Trust,
Belfast.
McCormack
o Elizabeth
B and
Henderson,
McCance
Lead
T (2006)
Cancer
Development
Nurse, Northern
of a
Ireland
framework
Cancer
for
Network.
personcentred
nursing. Journal of Advanced Nursing, 56(5): 1-8.
o Dr Val Wilson, Director of Nursing Research & Practice Development, the Children's
Schien E H
Hospital
(2004)
at
Organisational
Westmead, NSW,
culture
Australia.
and leadership. John Wiley and sons inc.
UK.
o Jayne Wright, Research Associate, University of Ulster
Titchen, A. (2001). Critical companionship: a conceptual framework for developing
expertise. Practice Knowledge and Expertise in the Health Professions. A. Higgs and
A. Titchen. Oxford, Butterworth Heinemann.
Wilson V. (2005) Developing a vision for teamwork. Practice Development in Health
Care, 4(1), 40-48.
April 2007
Cultural Observation Tool – version 4 20
Cultural Observation Tool version 5 – March 2007 1 91
91

Resident Narrative/Interview
Guide Questions
Preparation notes for the facilitator
The facilitator should provide the resident with information on the purpose of the interview
and obtain their formal consent. Always obtain permission from the resident before starting
the interview.
Examples of guide questions
1. Start by using an opening question such as, “how are you today?” The answer to this
may or may not be used in the narrative analysis.
2. “Can you describe what it is like being a resident/patient here?”
3. “Could you tell me something about your life when you were younger?”
4. “Tell me why you came to live here?”
5. “Could you tell me how you spend your days?” or “could you describe your day to me?”
6. “Is there anything else you would like to tell me about your life here?”
92
Appendix 7

Appendix 8
Quality of Life Exercise -
“My day, my way”
Developing Person-centred care for residents
The importance of getting to know the person, not just the resident, and what is important
to them in their daily life is central to the concepts underpinning person-centred care.
How can we help staff be more person-centred in their care for the individual person?
As part of the Person Centred Care Programme an innovative exercise “My day, my way” was
developed by the participants (PD group).
• This ‘getting to know me’ exercise can be carried out before a resident is admitted to
the unit, when they are admitted as part of their admission procedure, or as part of
their ongoing assessment.
• This can be completed with the residents by a family member/healthcare team
member.
• The information should be kept in the resident’s care plan which is accessible to all
staff.
• It should be reviewed and updated as part of the ongoing evaluation of the resident’s
care in collaboration with the resident.
• All new staff should familiarise themselves with the plan.
93

“My day, my way” (Example of Exercise)
Dear Healthcare Team,
I would like to share this important information with you.
Name: Mary Kelly Unit: Sandymount
What makes me happy?
• “I like to put my own makeup on in the morning, please don’t rush me. If you leave the
mirror and the makeup bag I will work away at it. I am not in a hurry.”
• “I love to get fresh air every day, if you can assist me to go to the garden. “
• “I love a lie in on a Saturday morning, I always did it at home. If you can put RTE Radio
One on for me. I love the chat on the radio.”
• “I don’t like to eat my meals with other people. Please let me sit on my own to have my
meals. I eat better that way.”
What makes me unhappy
• “Tea. I hate tea, always have, and I am not going to change now, please let staff know
that.”
• “Trousers. I have never worn a pair and I would prefer not to at this stage of my life.”
• “Loud music and the TV on at the same time. If you bring me in to the day room, keep
the noise level down please!”
• “Not to be consulted when planning my care. I hate when people talk over me like I am
not there!”
94

AIM (what is the overall intention of the action(s) proposed?)
AIM (what is the overall intention of the action(s) proposed?)
OBJECTIVE(S) (what are the steps needed to achieve the aim?)
OBJECTIVE(S) (what are the steps needed to achieve the aim?)
1.
1.
2.
2.
3.
3.
4.
4.
Appendix 9
ACTION
PLANNING
FRAMEWORK
WHAT EVIDENCE HAVE WE TO DEMONSTRATE THE NEED FOR THIS
ACTION
WHAT EVIDENCE
TO BE TAKEN
HAVE
(e.g.
WE
Observations
TO DEMONSTRATE
of practice;
THE NEED
PCNI;
FOR
PCCI;
THIS
CAI;
Patient
ACTION
stories;
TO BE TAKEN
other local
(e.g.
evidence)
Observations of practice; PCNI; PCCI; CAI;
Patient stories; other local evidence)
ARE THERE ANY STANDARDS, PROTOCOLS OR POLICIES IN EXISTENCE
ARE
THAT
THERE
WE NEED
ANY
TO
STANDARDS,
TAKE ACCOUNT
PROTOCOLS
OF? (e.g.
OR
HIQA
POLICIES
Standards;
IN EXISTENCE
local
THAT
standards/policies/protocols;
WE NEED TO TAKE ACCOUNT
National
OF?
standards)
(e.g. HIQA Standards; local
standards/policies/protocols; National standards)
© The Older Persons Services National Practice Development Programme. No part of this framework can be
reproduced © The Older without Persons the Services prior permission National Practice of the authors. Development Please Programme. contact bg.mccormack@ulster.ac.uk No part of this framework or can be
95
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95
1

OBJECTIVE(S) (what are the steps needed to achieve the aim?)
PERSON-CENTRED-PROCESSES
Engagement 1. Having
sympathetic
presence
2.
ACTION
PLANNING
FRAMEWORK
Knowing ‘self’
BY TAKING THE PROPOSED ACTION(S) WHICH OF THE FOLLOWING
ELEMENTS OF THE PERSON-CENTRED PRACTICE FRAMEWORK WILL WE
PROVIDE EVIDENCE OF ACHIEVING? (please tick 1 or more of the list below)
PREREQUISITES
Professionally Developed
competent interpersonal
skills
Commitment to
the job
Clarity of beliefs
and values
CARE ENVIRONMENT
AIM (what is the overall intention of the action(s) proposed?)
Appropriate Systems that Effective staff Organisational The sharing of Potential for
skill mix facilitate relationships systems that are power
innovation and
shared
decision
making
supportive
risk taking
Sharing decision
making
Providing for
physical needs
Working with Patient’s
Beliefs and Values
3.
BY TAKING THE PROPOSED ACTION(S) WHICH OF THE HIQA STANDARDS
WILL WE PROVIDE DIRECT AND INDIRECT EVIDENCE OF ACHIEVING?
(please see 4. attached list of HIQA standards mapped to the PD Programme)
WHAT EVIDENCE HAVE WE TO DEMONSTRATE THE NEED FOR THIS
ACTION TO BE TAKEN (e.g. Observations of practice; PCNI; PCCI; CAI;
Patient stories; other local evidence)
ARE THERE ANY STANDARDS, PROTOCOLS OR POLICIES IN EXISTENCE
THAT WE NEED TO TAKE ACCOUNT OF? (e.g. HIQA Standards; local
standards/policies/protocols; National standards)
© The Older Persons Services National Practice Development Programme. No part of this framework can be
reproduced without the prior permission of the authors. Please contact bg.mccormack@ulster.ac.uk or
Jan.dewing@btinternet.com for further information.
96
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reproduced 96 without the prior permission of the authors. Please contact bg.mccormack@ulster.ac.uk or
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2
1

Date action
will be
achieved
Person responsible for
coordinating the action
AIM (what is the overall intention of the action(s) proposed?)
OBJECTIVE(S) (what are the steps needed to achieve the aim?)
1.
ACTIONS
Action Resources Required People who will
participate in the
action
1.
2.
3.
4.
ACTION
PLANNING
FRAMEWORK
WHAT EVIDENCE HAVE WE TO DEMONSTRATE THE NEED FOR THIS
ACTION TO BE TAKEN (e.g. Observations of practice; PCNI; PCCI; CAI;
Patient stories; other local evidence)
ARE THERE ANY STANDARDS, PROTOCOLS OR POLICIES IN EXISTENCE
THAT WE NEED TO TAKE ACCOUNT OF? (e.g. HIQA Standards; local
standards/policies/protocols; National standards)
2.
3.
4.
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reproduced without the prior permission of the authors. Please contact bg.mccormack@ulster.ac.uk or 97
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5.
6.
7.
8.
3
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97
1

Identify AIM the (what stakeholders is the overall who must intention be invited of the to action(s) participate proposed?) in implementing the
proposed actions
OBJECTIVE(S) (what are the steps needed to achieve the aim?)
Identify the stakeholders who must be consulted with about the proposed actions
1.
and whose help may be sought
2.
3.
ACTION
PLANNING
FRAMEWORK
STAKEHOLDER ENGAGEMENT (this section operationalises the CIP
principles)
Identify the stakeholders who must be informed of the actions proposed
PROCESS 4. AND OUTCOME EVALUATION (what data will we collect along the
way and how will we know we have achieved our aim?)
WHAT EVIDENCE HAVE WE TO DEMONSTRATE THE NEED FOR THIS
ACTION TO BE TAKEN (e.g. Observations of practice; PCNI; PCCI; CAI;
Patient stories; other local evidence)
ACTION PLAN FORMULATED BY:
DATE: ARE THERE ANY STANDARDS, PROTOCOLS OR POLICIES IN EXISTENCE
STATEMENT
THAT
OF
WE
APPROVAL
NEED TO
BY
TAKE
DIRECTOR
ACCOUNT
OF NURSING
OF? (e.g.
(DoN):
HIQA
This
Standards;
action plan has
local
been
discussed standards/policies/protocols; with me. I am satisfied that the proposed National action(s) standards)
are achievable and I am prepared to support
the resources required to achieve the action plan.
Don’s Signature:
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98
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4
1

ACTION
PLANNING
FRAMEWORK
Practice Development
and
The National Quality Standards for Residential Care Settings for
AIM (what is the overall intention Older of the People action(s) proposed?)
This document shows how the Older Person’s Services National Practice
Development Programme will be contributing to delivery and achievement of the
National Quality Standards for Residential Care Settings for Older People (National
Health
OBJECTIVE(S)
Information
(what
and Quality
are the
Authority
steps needed
2007).
to
The
achieve
supplementary
the aim?)
criteria for
dementia-specific services are also included.
1.
Practice Development Programme Aims, Objectives and Outcomes
Overall aim of the programme: To implement a framework of person-centred nursing for
2.
older people across multiple settings in Ireland, through a collaborative facilitation model
and an evaluation of the processes and outcomes.
Objectives 3.
1. Coordinate a programme of work that can replicate effective Practice Development
processes in care of older peoples settings
2. Enable 4. participants/local facilitators and their Directors and managers to recognise the
attributes of person-centred cultures for older people and key practice development
and management interventions needed to achieve the culture (thus embedding
WHAT person-centred EVIDENCE care HAVE within WE organisations) TO DEMONSTRATE THE NEED FOR THIS
3. Develop person-centred cultures in participating practice settings.
ACTION TO BE TAKEN (e.g. Observations of practice; PCNI; PCCI; CAI;
4. Systematically measure or evaluate outcomes on practice and for older people
Patient stories; other local evidence)
5. Further test a model of person-centred practice in long-term care/rehabilitation settings
and develop it as a multi-professional model.
6. Utilise a participant generated data-set to inform the development and outcomes of
person-centred practice. ( Already designed and tested tools will be used to produce
the data set)
7. Enable local NMPDU facilitators to work with shared principles, models, methods and
processes in practice development work across older people’s services.
Section Standard Direct/Indirect
Section1:
Rights
1: Information Indirect
ARE THERE ANY 2:Consultation STANDARDS, and PROTOCOLS Participation OR Direct POLICIES 2.2; 2.3;2.4 IN EXISTENCE
THAT WE NEED
3:
TO
Consent
TAKE ACCOUNT OF? (e.g. HIQA
Direct
Standards;
3.1; 3.4
local
Indirect 3.2; 3.8; 3.9 3.3; 3.5.3.6
standards/policies/protocols; National standards)
3.7; 3.10
4:Privacy and Dignity Direct 4.1; 4.2; 4.4; 4.7;4.8
Indirect 4.3; 4.5;4.6
5:Civil, Political and Religious Direct 5.7; 5.8
Rights
Indirect 5.1;5.2;5.3; 5.6
6: Complaints Direct 6.1; 6.2;
Indirect 6.6
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reproduced without the prior permission of the authors. Please contact bg.mccormack@ulster.ac.uk or
Jan.dewing@btinternet.com
© The Older Persons Services
for
National
further information.
Practice Development Programme. No part of this framework can be
reproduced without the prior permission of the authors. Please contact bg.mccormack@ulster.ac.uk or 99
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5
99
1

7: Contract/Statement of Terms
and Conditions
Indirect
Section 2:
Protection
8: Protection Indirect 8.1;8.2;8.3
9: The Resident’s Care Plan Indirect
Section 3:
Health and
Social Care
Needs
10: Assessment Indirect
11: The Resident’s Care Plan Indirect
AIM (what is the overall intention of the action(s) proposed?)
Supplementary Criteria for
Dementia-Specific Residential
Care Units for Older People
Direct 11.7
12: Health Promotion Direct 12.2; 12.4
OBJECTIVE(S) (what are the steps needed to Indirect achieve 12.1;12;3 the aim?)
13: Health Care Direct 13.1; Indirect 13.2;
1.
14: Medication Management
15: Medication Monitoring and
Review
Indirect 14.3; 14.4; 14.9;14.10
Indirect
2.
16: End of Life Care Direct 16.1;16.2; 16.6;16.10
Indirect 16.3;16.4;16.5; 16.8
16.9
Section 4:
Quality of 3. Life
17: Autonomy and Independence Direct 17.1;17.4; 17.5;17.6; 17.7
Indirect 17.2;17.3
4.
Supplementary Criteria for
Dementia-Specific Residential
Care Units for Older People
17.10;
ACTION
PLANNING
FRAMEWORK
WHAT EVIDENCE HAVE WE TO DEMONSTRATE THE NEED FOR THIS
18: Routines and Expectations Direct 18.1;18.2;18.3;18.4
ACTION TO BE TAKEN (e.g. Observations of practice; PCNI; PCCI; CAI;
Indirect 18.5;18.6
Patient stories; other local evidence)
Supplementary Criteria for
Dementia-Specific Residential
Care Units for Older People
19: Meals and Mealtimes Direct
Direct 18.8; 18.9; 18.10
18.11
Indirect 18.7
20: Social Contacts Direct 20.1;20.2;20.3;20.5
Indirect 20.4
21: Responding to Behaviour that Direct 21.4;21.5;21.6;21.7;
is Challenging
Indirect 21.1;
ARE THERE ANY STANDARDS, PROTOCOLS OR POLICIES IN EXISTENCE
21.2;21.3;21.8;21.9-21.13;21.14-
THAT WE NEED TO TAKE ACCOUNT OF? (e.g. HIQA Standards; local
21.23
Section
standards/policies/protocols;
5: 22: Recruitment
National standards)
Indirect
Staffing
23: Staffing Levels and
Indirect
Qualifications
Indirect
Supplementary Criteria for
© The Older Persons Services National Practice Development Programme. No part of this framework can be 6
reproduced without the prior permission of the authors. Please contact bg.mccormack@ulster.ac.uk or
Jan.dewing@btinternet.com for further information.
100
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1

section 5:
staffing
Section 6: 25: Physical environment
Direct 25.8; 25.9;25.10; 25.11;
The Care AIM (what is the overall intention of the action(s) Indirect proposed?)
for the remainder
Environment
OBJECTIVE(S) (what are the steps needed to achieve the aim?)
26: Health and Safety Indirect
Section 7:
Governance
1.
27: Operational Management Indirect
and
Supplementary Criteria for Indirect
Management
2.
Dementia-Specific Residential
Care Units for Older People
3.
4.
Dementia-Specific Residential
Care Units for Older People
24: Training and Supervision
Supplementary Criteria for
Dementia-Specific Residential
Care Units for Older People
Supplementary Criteria for
Dementia-Specific Residential
Care Units for Older People
28: Purpose and Function
Supplementary Criteria for
Dementia-Specific Residential
Care Units for Older People
ACTION
PLANNING
FRAMEWORK
Direct 24.3; 24.8
Direct 24.9
Indirect
Direct 28.1
Indirect for the remainder
Direct 28.8;28.9;28.10
29: Management Systems Indirect
WHAT EVIDENCE
30: Quality
HAVE
Assurance
WE TO
and
DEMONSTRATE
Direct 30.1;30.3;30.4
THE NEED FOR THIS
ACTION TO Continuous BE TAKEN Improvement (e.g. Observations of Indirect practice; 30.2 PCNI; PCCI; CAI;
Patient stories; 31: Financial other local Procedures evidence) Not covered
32: Register and Residents Indirect
Records
ARE THERE ANY STANDARDS, PROTOCOLS OR POLICIES IN EXISTENCE
THAT WE NEED TO TAKE ACCOUNT OF? (e.g. HIQA Standards; local
standards/policies/protocols; National standards)
© The Older Persons Services National Practice Development Programme. No part of this framework can be 7
reproduced without the prior permission of the authors. Please contact bg.mccormack@ulster.ac.uk or
Jan.dewing@btinternet.com for further information.
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reproduced without the prior permission of the authors. Please contact bg.mccormack@ulster.ac.uk or 101
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101
1

Facilitator Guidance for
Claims, Concerns and Issues
(CCIs) Exercise
Claims, Concerns and Issues (CCIs) can be carried out as part of a formal evaluation or can be
used within various elements of PD. CCIs can, for example, be used to evaluate how effective
a meeting was, or can be used to set an agenda. Issues that arise on a ward can also be
addressed using CCI. This is a collaborative exercise.
Claims, Concerns and Issues originated from Guba and Lincoln (1989) Fourth Generation
Evaluation work.
• Claims are favourable assertions about the topic you are evaluating.
• Concerns are any unfavourable assertions about the topic and its implementation.
• Issues are questions that may be raised about the topic and its implementation; they
usually arise from concerns.
The group should use “how?” and “what?” questions to address the issues identified, for
example, if the concern was about poor communication within the unit.
The question could be:
• What can we do to improve our communication?
• How can we ensure that our communication within the unit is more effective?
Facilitating CCIs
You will need a flip chart, easel, paper and a pen. You may need three post-it notes.
Put up three headings (Claims, Concerns, Issues) on a flipchart sheet. Invite group members
to put forward their claims first, followed by their concerns. Ensure the suggestions from
each member are all captured and not discussed or modified by other group members. Give
the group members an opportunity to add any final contributions. The facilitator should ask
group members to identify any questions that can be developed from either the claims or
concerns. Remember to use the “how?” and “what?” questions.
Develop action and evaluation plans from the work to be undertaken.
102
Appendix 10

Claims, Concerns and Issues (CCIs) Template
CLAIMS: What positive statements would I make about the
programme?
......................................................................................................................................................................................
......................................................................................................................................................................................
......................................................................................................................................................................................
......................................................................................................................................................................................
......................................................................................................................................................................................
......................................................................................................................................................................................
......................................................................................................................................................................................
CONCERNS: What are my concerns about the programme?
......................................................................................................................................................................................
......................................................................................................................................................................................
......................................................................................................................................................................................
......................................................................................................................................................................................
......................................................................................................................................................................................
......................................................................................................................................................................................
......................................................................................................................................................................................
ISSUES: What questions do I have about the programme?
......................................................................................................................................................................................
......................................................................................................................................................................................
......................................................................................................................................................................................
......................................................................................................................................................................................
......................................................................................................................................................................................
......................................................................................................................................................................................
......................................................................................................................................................................................
103

Notes
104

105

Notes
106

107

Notes
108

109

Notes
110

Mr. Patrick Glackin
Acting Area Director Nursing and Midwifery Planning and Development
HSE West
Unit 4, Central Business Park, Clonminch, Portlaoise Road,
Tullamore, Co. Offaly.
Tel: (057) 93 57861/57866 Fax: (057) 93 57871
Email: patrick.glackin@hse.ie
© Enhancing Care for Older People - A Guide to Practice Development Processes
to Support and Enhance Care in Residential Settings for Older People
2010
ISBN: 978-1-906218-35-5
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