5Practice Development in Health Care, 4(1) 5–13, 2005 © Whurr Publishers Ltd

Introduction

Interest in practice development is growing inAustralia, and much of the interest has beensparked by the reported success of practicedevelopers in the UK. Drawing on these reportsa practice development programme was imple-mented in a cardiothoracic surgical unit in anacute teaching hospital in Melbourne, Australia.The unit, which is part of a group of services inthe cardiac division of the hospital, employs over80 members of staff including nurses, alliedhealth professionals, medical and support staff.Divisional directors from medicine, allied healthand nursing lead the team at the executive level.

The 23-bed unit has 10 high dependencyand 13 monitored beds. Care is provided forcardiac patients on day one post-surgery and

immediately following surgery for thoracicpatients. The unit has been affected by signifi-cant changes over the past 20 years including a220% increase in patient throughput andincreased patient age and morbidity.

As part of their commitment to improvingpatient care, the cardiac division formed apartnership with the University of Melbourneto develop, implement and evaluate a practicedevelopment programme.

At a review of the progress of the pro-gramme, a number of challenges to sustainabili-ty were identified. In particular, it was identifiedthat there was a need to consolidate systematicprocesses. The challenges encountered and thestrategies to manage them are described in thispaper. In the practice change literature there arefew stories of challenge or failure (Rogers,

INNOVATION IN PRACTICE

Systematic processes for successful, sustainable practice development

Catherine Barrett—PhD Candidate, School of Nursing and Centre for Programme Evaluation,University of Melbourne; Director, Desirable Outcomes Pty LtdJenni Angel—Clinical Nurse Educator, Cardiothoracic Surgical Unit, Royal MelbourneHospital, Melbourne, AustraliaMary Gilbert—Nurse Unit Manager, Cardiothoracic Surgical Unit, Royal Melbourne Hospital,Melbourne, AustraliaChristina Bouras—Social Worker, Cardiothoracic Surgical Unit, Royal Melbourne Hospital,Melbourne, AustraliaKerryn Thompson—Nurse Unit Manager, Cardiothoracic Surgical Unit, Royal MelbourneHospital, Melbourne, AustraliaElizabeth Singleton—Manager, Cardiac Hospital in the Home, Royal Melbourne Hospital,Melbourne, Australia

Abstract: Despite reports that a systematic approach to practice development is desirable, few practicedevelopers describe the application of a systematic process. In the present study a practice development pro-gramme was implemented with limited systematic supports. At a mid-programme review it became appar-ent that these supports needed to be consolidated to ensure programme success and sustainability. In thispaper we describe how the need for a systematic approach was identified, what strategies were implement-ed and their effects. Additionally we reflect on how, as a result of these actions, we came to rethink howwe defined and valued systematic processes.

Key words: practice development, sustainable change, systematic process, systems thinking

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6 Barrett et al.

1995). While we hope to publish many stories ofsuccess, we also believe the challenges offer avaluable learning opportunity for practicedevelopers. Additionally, we believe the publi-cation of our reflections exemplifies practicedevelopment principles in action.

Defining practicedevelopment

The term practice development is often misun-derstood and confused with professional devel-opment or practice change. The definitionshared by programme participants was that prac-tice development is ‘a continuous process ofimprovement towards increased effectivenessin patient-centred care. This is brought aboutby helping health care teams to develop theirknowledge and skills and to transform the cul-ture and context of care. It is enabled and sup-ported by facilitators committed to systematic,rigorous, continuous processes of emancipatorychange that reflect the perspectives of serviceusers’ (Garbett and McCormack, 2002: 88)and service providers.

This definition was adopted because ofthe emphasis on patient-centred care and onsystematic and emancipatory change. Bypatient-centred care we mean an approach tocare in which health professionals try tounderstand the meaning of illness throughpatients’ eyes (McWhinney, 1989) and try toinvolve patients in decisions about their care(McWhinney, 1989). The emphasis on sys-tematic processes reflected our plan to evalu-ate the whole system of care. Additionally,the emphasis on emancipatory change high-lighted our intention to facilitate new ways ofseeing and understanding practice and to cre-ate momentum for practice change driven byclinicians.

Negotiating a clinical–university partnership

An action research methodology was used andprovided the scope for partnership between theexternal facilitator and the programme partici-pants. Another characteristic of action research

is the importance placed on negotiating siteentry (Dick, 2003). The partnership was negoti-ated over an eight-month period, after which anapplication was lodged with the hospital ethicscommittee. The programme structure includedan evaluation of care, followed by a six-monthperiod of practice change. The initial plan for a12-month programme was reduced to a six-month trial period to enable a decision to bemade about the value of continuing. Rogers(1995) notes that innovations are not generallyimplemented without a trial period to determinetheir usefulness.

The negotiated partnership includedshared facilitation using a ‘double act’ or insid-er/nurse educator–outsider/researcher model(Titchen and Binnie, 1993). Facilitators wereappointed from nursing, allied health and med-icine; and nurse managers took on an informal,but critical role in facilitation.

To ensure executive support for the pro-gramme, plans were made to establish an advi-sory committee involving facilitators and theexecutive. Attempts to establish the commit-tee were unsuccessful and as a consequenceengagement of the executive occurred on an‘as needs’ basis.

Programme outline

Programme implementation began with anevaluation of care using Fetterman’s (2001)Empowerment Evaluation. This evaluationmethod involved interdisciplinary workshopsto develop a shared mission, to identify keyactivities critical to the function of the unit andto rate the performance of the unit in each keyactivity. Following these workshops, data werecollected through staff and patient interviewsand surveys to substantiate ratings given byworkshop participants. Data were thenanalysed and a series of reports generated forstaff and patients. In addition to a traditionalevaluation report (Barrett, 2003) a series ofposters summarizing evaluation findings weredeveloped for patients and staff.

Twelve projects were implemented inresponse to the evaluation report includingprojects to enhance:

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7Processes for successful practice development

● Patient-centred care.● Teamwork.● Pain assessment and management.● Discharge planning.● Patient education.● Nurse education.● Nurse handover. ● Nurse support.● Medication prescribing.● Patient rest.● Patient involvement in decisions about

care.

In addition to the mid-programme review,an evaluation was planned for 12 months afterprogramme implementation, to clarify pro-gramme outcomes. The outcome evaluationwill involve a repeat of the patient and staffsurveys and interviews

Consensus to continue

The enthusiasm of facilitators for the pro-gramme increased during the implementationphase to a point where, at the completion of thesix-month trial, there was consensus amongfacilitators to continue. A noticeable shiftoccurred from the initial ‘agreement’ to imple-ment the programme to a sense of self-determi-nation, or greater commitment to the pro-gramme. This enthusiasm was shared among90% of clinicians who voted to continue withthe programme, which is particularly significantgiven that enthusiasm, or commitment, of par-ticipants enhances the likelihood of a successfuloutcome (Senge, 1992).

Having established staff commitment,facilitators met to develop strategies to ensuresustainability of the programme beyond theinvolvement of the external facilitator. To aidreflection on progress to date facilitators com-pleted a checklist of factors needed to ensuresuccessful change. The checklist, which wasdeveloped by Øvretveit (2004) and adapted tosuit the practice development context (Barrettand Gilbert, 2004), clarified the need to con-solidate a systematic approach to ensure pro-gramme success.

Defining a systematicapproach

Applying systems thinking mightinvolve new ways of seeing practiceand the patient.

Practice developers highlight the impor-tance of a systematic approach to change. Forexample, a systematic approach is reported toassist in ensuring successful outcomes and cred-ibility and determining cost-effectiveness(Garbett and McCormack, 2002). Others notethat the value of a systematic approach is notalways recognized (Kitson and Currie, 1996;McCormack et al., 1999).

While a systematic approach to practicedevelopment appears to be valued by practicedevelopers, there is little exploration of what itmeans to take a systematic approach. In gener-al terms, being systematic refers to having asystem or a plan. In the context of practicedevelopment this might translate to a plannedprocess of change, rather than an ad hocapproach.

However, a systematic approach to prac-tice development involves more than planningthe process of change. The implementationand evaluation of the programme highlightedthe centrality of systems thinking to a system-atic approach. Senge (1992) describes thevalue of systems thinking in his seminal workon the fifth discipline. In this work Sengeexplores five disciplines, or bodies of theoryand technique, to help us understand how ouractions affect our world. The fifth discipline issystems thinking. This discipline is the corner-stone of all the disciplines, i.e. shared vision,ways of seeing the world, team learning andmotivation. Systems thinking is about seeingwhole systems, or the inter-relationshipsbetween parts, in order to better understandand change systems.

Applying systems thinking to practicedevelopment might involve new ways of seeingpractice and the patient. Seeing the whole sys-tem of care enables health professionals tounderstand the effect of their practice on the

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8 Barrett et al.

patient, families, other disciplines, depart-ments and services. Similarly, seeing the inter-relationships between parts might enablehealth professionals to see the patient as awhole person, rather than simply seeing thepresenting medical condition.

In essence, a systematic approach to prac-tice development involves planned processesof change, seeing whole systems of care andseeing the patient as a person with individualneeds.

Indicators of the need toconsolidate systematicprocesses

A number of strategies were implemented inthe planning phase to ensure a systematicapproach. For example, facilitators wereappointed from each discipline, consultationoccurred with a range of stakeholders, and proj-ect reports were structured to incorporate thehospital’s approach to quality improvement.Additionally the evaluation method encom-passed the whole system of care and includedthe perspectives of service providers and serviceusers. The evaluation of the whole system ofcare complements the traditional approach toservice improvement which is limited to theimplementation of key performance indicatorsdeveloped in response to patient complaints,governmental regulations or litigation.

While attempts were made to take a sys-tematic approach, it became apparent thatthey were insufficient to ensure programmesustainability and success. At the mid-pro-gramme review a number of behaviours threat-ening the success of the programme were iden-tified. These behaviours included a failureadequately to engage the executive, reluctanceof project co-ordinators to meet with facilita-tors, difficulty ensuring involvement of staffacross disciplines and departments, and strug-gles for project control. Open communicationregarding these behaviours occurred, but wasnot successful in eradicating them. It was notuntil facilitators explored the behaviours andidentified the underlying causal mechanism

that successful management strategies weredeveloped. Each of these patterns of behaviouris outlined below.

Local focus

Senge (1992) identified that in organizationsdecisions may be made at a local or central level.In hierarchical organizations control is central-ized, and staff are expected to comply with deci-sions made by senior management. In contrast,learning organizations value localness, or mov-ing decisions down the organizational hierarchyto unleash commitment and encourage staff tobe responsible for producing results.

A local approach underpinned the practicedevelopment programme, with some considera-tion for central needs. The local component ofthe programme involved working with healthprofessionals to evaluate care and, in responseto this evaluation, to implement practicechange. The central, or organizational, compo-nent of the programme involved linking thesechanges to hospital key performance indicators.

Several months into the implementationof practice change the organization appointeda quality manager to the cardiac division. Inthe absence of an advisory committee, involv-ing the executive and the newly appointedquality manager, there was not a shared under-standing of the value of the practice develop-ment programme. Consequently, as highlightedin Figure 1, a quality programme was imple-mented in addition to the practice develop-ment programme.

Local (unit) practice

developmentprogramme

Central (organizational)

quality programme

Figure 1. A local approach to practice development.

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9Processes for successful practice development

The participation of staff in two pro-grammes was impractical and created duplica-tion. Facilitators identified the need toincrease engagement with the executive todetermine how the two programmes could becombined. The programmes had much in com-mon; arguably they were both quality pro-grammes and shared the common aim: toimprove patient care. However, the practicedevelopment programme was a little myopic,or, as described by Senge (1992), failed toappreciate the effect of changes on the largersystem. Through consultation with the execu-tive and the quality manager, facilitators devel-oped a new quality model, based on practicedevelopment principles (see Figure 2).

The new model continues the emphasis onchange determined by an evaluation of careincluding the perspectives of staff and patients.However, the perspectives of staff are no longerlimited to clinicians but include the executiveand the quality manager. Consequently, hospi-tal and divisional key performance indicatorssuch as critical incidents, medication prescrib-ing, falls reduction and documentation areincluded in the evaluation. This new modelprovides a synergy between the unit and orga-nizational needs.

Without an advisory committee there wasno system for reporting to the executive toensure the programme was linked to organiza-tional needs. The engagement of the executivehas not only provided a link to organizationalneeds but has also increased executive supportfor the programme.

The ‘just do it’ approach

Despite recognition that evaluation provides theopportunity to improve activities, justifyresources and identify what has been achieved(Wadsworth, 1991), it is not always consideredintegral to practice change. On the contrary,there is a tendency to implement change, or ‘justdo it’ without evaluation. Typically the ‘just doit’ approach involves no planning or evaluation;change is simply implemented and forgotten.

There were a number of reasons why this

approach was preferred. For some project co-ordinators the ‘just do it’ approach was a quickfix, whereas adding an evaluation on top ofproject implementation required more timeand energy.

For others, evaluation was avoided becauseof a fear it might not show a positive outcome.Some project co-ordinators were so passionateabout their projects and invested so much inchanging practice they could not face theprospect of not achieving their goals. This fearoften escalated when obstacles were encoun-tered, and consequently some projects lostmomentum or stopped.

Other project co-ordinators consideredevaluation to be unnecessary, particularlywhen they had ‘faith’ or an ‘intuitive knowl-edge’ that their project was going to be suc-cessful. Identification of this theme in reflec-tions on the programme surprised facilitators,who reported there was increasing pressure todemonstrate outcomes and a strong pulltowards a perspective of ‘if it’s not science, youjust don’t do it’.

While it was anticipated that most projectswould be successful, without evaluation therewas often disagreement about what had beenachieved. Several project co-ordinators regret-ted not evaluating outcomes at baseline, andconsequently collected data mid-interventionto create a new baseline. Increasingly, projectco-ordinators recognized that the value of eval-

Practice developmentprogramme

Organizational key performance indicators

Figure 2. A synergistic local-central approach topractice development.

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uation was having something to show for theirinvestment and hard work.

Chasing change

Facilitators met with project co-ordinators to assistin planning steps involved in project implementa-tion and evaluation. Most co-ordinators wereexcited about their new role and confident theywould not need ongoing support from facilitators.Consequently, invitations to set times to discussprogress of projects were generally declined.

Without a system to monitor the progressof projects or support project co-ordinatorsmany projects reached a standstill and adynamic evolved in which the facilitators‘chased’ project co-ordinators for progressreports. In contrast, in one project, a system forreporting progress enabled steady progress ofthe project despite a number of obstacles.

Clearly, without a formal system for sup-porting staff, momentum was difficult to main-tain. A number of hypotheses are proposed toexplain this.

In the first place, project co-ordinatorswere charged with enthusiasm for changingaspects of practice they were passionate about.While they were excited, many had little expe-rience in project co-ordination and wereunprepared for the obstacles they encountered.Senge (1992) notes that we feel powerless tocreate the change we want. This sense of pow-erlessness was exacerbated when the enthusi-asm of project co-ordinators was not shared bytheir colleagues and when, despite consider-able effort, there was ‘nothing to show’ fortheir input. For example, project co-ordinatorsunderstood the importance of their project topatient care but this belief was not alwaysshared with their colleagues.

Pressure from peers also arose in relation toconflicting beliefs about what constituteswork. For many staff, patient care was aboutpatient contact, which had a sense of urgencyand was considered to be ‘real work’. On theother hand project work was not seen as anessential aspect of patient care and thereforewas something to be done if there was ‘spare

time’. However, in busy health care environ-ments ‘spare time’ rarely presents. A series ofcrises arise on a daily basis from lack of staff ormedical emergencies. Spare time for importantaspects of patient care such as quality improve-ment activities is rarely offered but rather,needs to be made. Taking the opportunity to dowhat is important as well as what is urgent isrequired to cut the cycle focusing on crisesalone (Covey, 1990). In effect there was a needto increase clinicians’ awareness of the long-term benefits of the projects for patient care.

Uni-disciplinary focus

To be effective, a team must be morethan a collective of individualspursuing their own tasks.

Recent studies have demonstrated thatteamwork can improve health care outcomes(Curley et al., 1998). Many studies havefocused on the effectiveness of the model ofteamwork as a strategy to improve outcomes. Ina traditional multidisciplinary model of team-work each discipline makes a unique contribu-tion, independent of other disciplines (Massey,2001). While this is still the case in an inter-disciplinary model, the key difference is thatinformation processing and problem solvingmove from an individual to a collectiveapproach (Warren et al., 1998). To be effective,a team must be more than a collective of indi-viduals pursuing their own tasks (Woodruff andMcGonigel, 1998) and there must be an under-standing that no discipline can be viewed inisolation since the practice of each intercon-nects (Humphris and MacLeod Clark, 2002).

One of the aims of the practice develop-ment programme was to ensure an interdisci-plinary approach to improving patient care.However, given the complexity of co-ordinat-ing interdisciplinary meetings, a default unidis-ciplinary approach was often assumed. Whilethe exclusion of stakeholders from other disci-plines was not intentional it was potentiallydamaging. For example, some staff were told

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about changes affecting their practice but werenot consulted on the change. This often led tostaff resistance and threats to project success.In contrast, in projects where interdisciplinarycollaboration occurred, project momentumwas unhindered and staff reported betterunderstanding of each others’ roles and oflearning and teaching across disciplines.

Continuity of care

Three years before the implementation of theprogramme, the unit functioned as an integrat-ed care unit. The unit provided admissionassessment, intensive care and inpatient admis-sion until discharge to cardiac hospital in thehome and cardiac rehabilitation. A year later,amalgamation with the general intensive careunit meant intensive care was provided forpatients in a geographically separate unit. Thefollowing year the implementation of day-of-surgery admission meant preadmission assess-ment was conducted in a geographically sepa-rate unit. As a consequence of these changes,patient care was delivered by six services acrossthe cardiac division.

Senge (1992) suggests that with increasingcomplexity there is an even greater need forsystems thinking. The challenge this complex-ity presented to staff was to ensure continuityof care across six services. Continuity of carewas reportedly supported by staff who workedacross a number of services and byexecutive/senior staff meetings for the cardiacdivision. Additionally, shared offices betweennurse managers from different services acrossthe cardiac division fostered good workingrelationships and provided the opportunity todiscuss values and goals.

However, there were a number of indica-tions that opportunities existed for improve-ment. For example, in one project two depart-ments shared a project aim but developed con-flicting change strategies. The conflict was notidentified until staff from both departments metto discuss the project. Over a number of meet-ings a deeper understanding of each departmentdeveloped and the change strategy was refined

to incorporate the needs of both departments.Until staff from the departments met there wasdifficulty seeing the whole system of care, orunderstanding how changes proposed in onedepartment could affect another.

Senge (1992) explores this phenomenonand identifies that we have difficulty seeingwhole systems because we have been taught tobreak apart problems and can no longer see theconsequences of our actions. Senge (1992) addsthat until we understand the relationshipbetween parts of a system, change will not beeffective.

Project drift

In complex environment interventions orchange, aims may be adjusted as they are imple-mented to ensure successful outcomes.Furthermore, action researcher responsiveness orplanning changes in response to the needs ofparticipants is desirable. However, in two proj-ects a less desirable, unplanned change or ‘drift’occurred. For example, in one project a shiftfrom the planned action to a new action waslargely unnoticed. In discussion, project co-ordi-nators identified that while the new actions wereuseful they did not replace the initial, plannedaction. Consequently, strategies were identifiedto ensure the initial actions were implemented.While the drift was viewed as harmless, facilita-tors identified the need to monitor any futuredrifts to ensure all changes in project activitieswere desirable.

Letting go

Facilitating practice development requires let-ting go of the desire to control change andallowing others to put their good ideas intopractice. Some facilitators experienced difficul-ty letting go because of the excitement generat-ed by a project, or because of a fear that thestandard of work would drop if it was not done‘my way’. Differing styles were interpreted as dif-fering standards of work and presented a chal-lenge for facilitators who felt responsible forwork standards.

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An adverse consequence of being unableto let go was an unmanageable workload andseveral facilitators regretted missing the oppor-tunity to involve other staff in changing theirpractice thereby simultaneously reducing theirown workload.

Discussion of this sensitive aspect of prac-tice change was both challenging and reward-ing. Gaps between espoused and actual valuesand beliefs were exposed and provided theopportunity to practise letting go.

Consolidation of systematicprocesses to ensure successand sustainability

Through reflection on the inter-relationshipsbetween these behaviours, facilitators identifieda common underlying theme. Each behaviourwas related to a lack of systematic processes tosupport change. It was not until this understand-ing was reached that effective managementstrategies were developed. The primary strategiesimplemented included establishing a unit levelsupport group and the engagement of the execu-tive and the quality manager.

The primary aim of the support group was toassist staff involved in practice change. All proj-ect staff were required to report to the supportgroup on a regular basis. This led to early identi-fication of obstacles and ensured project co-ordi-nators understood that an evaluation assisted inmaintaining the momentum of change. Supportgroup minutes were posted in the unit diary anddiscussed at unit meetings to ensure all staff wereaware of and supportive of the projects. An addi-tional aim of the support group was to ensure afocus of the whole system of care. To ensureinterdisciplinary involvement the group had rep-resentation from all disciplines and to ensurecontinuity of care, stakeholders from otherdepartments were invited to attend meetings.

Engagement of the executive and the qual-ity manager were viewed as an important aspectof a systematic approach. To ensure thisoccurred, facilitators met with the quality man-ager and divisional directors from nursing, med-icine and allied health to brief them about the

progress of the programme. Following thesemeetings an advisory committee was estab-lished to ensure structured communication. Asa consequence of these strategies opportunitiesarose to negotiate for the resources necessary tosustain the programme, in particular fundingfor a facilitator and research support.Additionally, the programme was written in thedivisional operations plan.

Conclusion

A mid-programme review provided the opportu-nity to reflect on threats to the success and sus-tainability of the practice development pro-gramme, in particular insufficient systematicprocesses.

In the absence of sufficient systematicprocesses there was inadequate support for cli-nicians co-ordinating practice change.Consequently, it was difficult to maintain themomentum and focus of change and there wasa failure to recognize the value of evaluationand of involving stakeholders whose practicewas affected. Furthermore, the lack of system-atic processes meant the practice developmentprogramme was not adequately linked to thestrategic direction of the organization.

Implementing a systematic approach topractice development was surprisingly simple.However, perhaps this could not have beenachieved without first learning the value of itor understanding what was meant by it.

Acknowledgements

The authors would like to thank AngelinaZagon for her feedback on this paper.

References

Barrett C (2003). The Practice DevelopmentProgramme: Data Collection Summary. Melbourne:2 West, Royal Melbourne Hospital and School ofNursing and Centre for Programme Evaluation atthe University of Melbourne, August.

Barrett C, Gilbert M (2004). A tool to identify opportu-nities to build the potential success of practicedevelopment. Unpublished manuscript, Melbourne.

12 Barrett et al.

PDHC 4.1 crc 3/18/05 8:44 AM Page 12

Covey S (1990). The Seven Habits of Highly EffectivePeople: Restoring the Character Ethic. New York:Business Library.

Curley C, McEachern E, Speroff T (1998). A firm trial ofinterdisciplinary rounds on the inpatient medicalwards: An intervention designed using continuousquality improvement. Medical Care 36: AS4–12.

Dick B (2003). Entry and contracting. Session 3: Actionresearch and Evaluation on line.www.uq.net.au/action_research/areol.areol-ses-sion03.html. Southern Cross University and theSouthern Cross Institute of Action Research.

Fetterman D (2001). Foundations of EmpowermentEvaluation. London: Sage.

Garbett R, McCormack B (2002). A concept analysis ofpractice development. Nursing Times Research 7:87–100.

Humphris D, MacLeod Clark J (2002). Future HealthWorker Project 2002. Faculty of Medicine, Healthand Biological Sciences, University ofSouthampton.

Kitson A, Currie L (1996). Clinical practice develop-ment and research activities in four district healthauthorities. Journal of Clinical Nursing 5(1): 41–51.

Massey C (2001). A transdisciplinary model for curricu-lar revision. Nursing and Health Care Perspectives22: 85–8.

McCormack B, Manly K, Kitson A, Titchen A, Harvey G(1999). Towards practice development – A vision inreality or a reality without a vision? Journal ofNursing Management 7(5): 255–64.

McWhinney IC (1989). The need for a transformed clin-

ical method. In M Stewart, D Roter (eds.)Communicating with Medical Patients. NewburyPark: Sage Publications, pp. 25–57.

Øvretveit J (2004). Change Achievement SuccessIndicator (CASI). Institute of Health Improvementhttp://qualityhealthcare.org/qhc

Rogers E (1995). Diffusion of innovations. New York:Free Press.

Senge P (1992). The Fifth Discipline: The Art andPractice of the Learning Organization. MilsonsPoint: Random House.

Titchen A, Binnie A (1993). Research partnerships:Collaborative action research in nursing. Journal ofAdvanced Nursing 18: 858–65.

Wadsworth Y (1991). Everyday evaluation on the run.Melbourne: Action Research Issues Association.

Warren M, Houston S, Luquire R (1998). Collaborativepractice teams: From multidisciplinary to interdisci-plinary. Outcomes Management for NursingPractice 2: 95–8.

Woodruff G, McGonigel M (1998). Early childhood spe-cial education: Birth to three. In J Jordan, JGallagher, P Hutinger, M Karnes (eds.) EarlyChildhood Special Education: Birth to Three.Reston: Council for Exceptional Children, pp.163–82.

Address for correspondence: Catherine Barrett,Director, Desirable Outcomes Pty Ltd., P.O. Box1392, Carlton 3053, Victoria, Australia. Email:cbarrett@desirableoutcomes.com.au

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