A PLURALISTIC EVALUATION OF THE PEBBLES AND KOHATU NURSING AND

MIDWIFERY LEADERSHIP PROGRAMMES

FINAL REPORT November 2011

Prepared By: Dr Philippa Miskelly (Principal Investigator, Waikato District Health Board | School of Nursing, University of Auckland, New Zealand) Mrs Lindsay Duncan (Nurse Co-ordinator Practice Development, Waikato District Health Board, Hamilton, New Zealand) Professor Ken Walsh (Nursing Development and Research Unit, School of Nursing, Midwifery & Indigenous Health, University of Wollongong, Australia) Research Advisors: Associate Professor Cheryle Moss (School of Nursing and Midwifery, Faculty of Medicine, Nursing and Health Sciences, Monash University, Melbourne, Australia) Dr Kay McCauley (School of Nursing and Midwifery, Faculty of Medicine, Nursing and Health Sciences, Monash University, Melbourne, Australia) Professor Wendy Cross (School of Nursing and Midwifery, Faculty of Medicine, Nursing and Health Sciences, Monash University, Melbourne, Australia)

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ACKNOWLEDGEMENTS

The research team would like to acknowledge and thank the following people for their support and contribution to this project:

• All participants and respondents (staff nurses, midwives, nurse educators and clinical nurse managers) who gave so generously of their time and thoughts

• Jane Lawless and Rhonda McKelvie (Nurse Co-ordinators, Practice Development)

• Sue Hayward, Director of Nursing & Midwifery (Waikato District Health Board) • Michael Bland (Clinical Nurse Director, Professional Development Unit, Waikato

District Health Board) • Professional Development Unit colleagues (Waikato District Health Board) • Dr Robyn Cant, Monash University, for her generous and timely assistance with

the quantitative analysis • Robyn Fenneman, for doing such a great job transcribing the interviews.

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TABLE OF CONTENTS Page No.

Executive Summary 4 - 7 1. Introduction 8 2. Background i) Generic Leadership Training, Waikato DHB 8 - 10 ii) Pebbles and Kohatu Programmes 10 - 12 iii) Pebbles and Kohatu Programme Content 12 - 13 iv) The Role of Practice Development 14 3. Literature Review i) Nursing in the 21st Century 15 - 16 ii) Nurse Leadership 17 - 18 iii) Leadership Preparation 19 - 21 4. Evaluation of Pebbles and Kohatu Programmes i) Research Process 22 ii) Research Question 22 - 23 iii) Research Methodology 23 - 25 iv) Ethical Approval 25 5. Research Findings i) Survey Results 25 - 30 ii) Stakeholder Perspectives: Focus Group/ 30 - 31

Individual Interviews 31 - 32 Themes: Expectations 31 - 32 Confidence 32 - 33 Aspiration 34 - 35 Resilience 35 - 36 ‘Big Picture’ 36 - 37 Value/Investment 38 - 40 Mentorship 40 Course content 41 Pebbles nomenclature 41

6. Study Limitations 41 - 42 7. Discussion 42 - 45 8. Conclusion 45 9. Recommendations 46 - 47 References 48 - 50 Appendices

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EXECUTIVE SUMMARY

When a pebble is dropped into a pool of water ripples occur and it was a ripples-of-influence

metaphor that influenced both the naming and ideological underpinnings of the Pebbles and

Kohatu1 programmes. These programmes were instituted at the Waikato District Health Board

in 2007 and 2008 respectively in order to fill a ‘gap’ that had been noted by the Nurse Co-

ordinators Practice Development when they were working with nursing and midwifery staff in

acute clinical and community settings. Ostensibly the programmes concentrated on assisting

nurses and midwives to “realise their individual and professional potential” utilising Practice

Development methodologies. Increasingly these programmes focused on the development of

leadership skills for clinically-based nurses and midwives and Carol Huston’s 2008 article on

leadership competencies required of nurses by 2020 became integral to the direction and

content of Pebbles and Kohatu. By mid-2010 eighty nurses and midwives had attended these

programmes and the Professional Development commissioned an evaluation to ascertain

what effect, if any, the programmes had had on participants. This evaluation which began in

August last year, has now been completed and the results are detailed in this report.

The methodology used to evaluate Pebbles and Kohatu was based around a pluralistic

evaluation approach and was constructed as a formal research project. Approval for this

approach was received from the Northern Y Regional Ethics Committee on the 28th of July

2010. The aims of the research were to:

1) Evaluate the impact and influence Pebbles and Kohatu have had on participants

in relation to their individual practice; and to

2) Evaluate the impact and influence Pebbles and Kohatu have had on participants

in relation to their general contribution to nursing within the Waikato District

Health Board.

The research involved the collection of both quantitative and qualitative data and the methods

and analytical strategies utilised are described in detail in this report.

1 The name Kohatu is contentious. When the Nurse Co-ordinators Practice Development decided to set up a ‘sister’ Pebbles programme for Maori nurses and midwives, advice received from Te Puna Oranga indicated that Kohatu was an appropriate word to use. However, there is some now debate about this translation.

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The nurses, midwives and charge nurse/midwife managers who participated in this study

were generally positively supportive of the Pebbles and Kohatu programmes. They

considered the programmes had assisted in developing participants’ confidence levels,

aspirations and resilience. Participants described gaining a greater appreciation of social and

economic factors which influence health policy direction at government and ministry levels

and the manifestation of these aspects at District Health Board level. A number of

participants also reported how Pebbles and Kohatu ‘re-energised’ their interest in post-

graduate study as well as their engagement with and use of evidence-based practice.

The literature highlights a plethora of leadership theories and models. The development of

nursing leadership capabilities is considered an important factor when it comes to the

continued recruitment and retention rates of nursing and midwifery staff, and, importantly, to

improved health outcomes for patients. However, findings from this study point to a lack of

clear direction from the organisation in relation to Pebbles and Kohatu aims, objectives and

learning outcome expectations.

This evaluation also noted that at present the Waikato District Health Board does not have a

nursing succession plan. The evidence suggests that this should be an integral part of the

strategic direction of the organisation and the nursing profession. Any clinical nurse/midwife

leadership programme should then be able to recruit participants according to a needs-based

analysis and develop programmes reflective of the skill-base required.

Recommendations resulting from this evaluation are:

The Pebbles and Kohatu programmes received a generally positive endorsement from

research participants and respondents. In order to retain and build on gains made to date the

following recommendations are made:

1. The literature alludes to levels of confusion concerning the terms

nursing/midwifery ‘leadership’ and ‘management’. It is recommended that the

Waikato District Health Board’s Professional Development Unit be tasked with

defining ‘clinical nursing/midwifery leadership’ as it pertains to the wider

organisation in order to identify potential leadership training requirements.

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2. Evidence from the literature points to the necessity for health care organisations

to develop leadership succession plans in order to address patient care and

safety issues as well as the nursing/midwifery work environment. It is

recommended that the Professional Development Unit, in consultation with the

Nursing Directorate, be tasked with researching and drafting a nursing/midwifery

leadership succession plan which is strategically aligned to overall Waikato

District Health Board and Health Workforce New Zealand goals.

3. The literature clearly outlines the need for organisational direction and support in

regard to clinical nursing/midwifery leadership programmes. Data from this study

indicated low-level direction and support for the programmes. It is recommended

that the Professional Development Unit, along with support from the Nursing

Directorate, undertakes a needs-based assessment in relation to both a

leadership succession plan and, pertaining to this, clinical nursing/midwifery

leadership requirements within the District Health Board.

4. If the Nursing Directorate directs the Professional Development Unit to continue

implementation and facilitation of a clinical nursing/midwifery leadership

programme it is recommended that programmes establish clear aims and

learning objectives. It is further recommended that these aims and objectives be

outlined in writing and circulated to all course participants and their CNMs prior to

the commencement of any programme. The implementation of a feedback loop

should also be an integral part of any learning outcomes.

5. In order to best meet the staff development requirements it is recommended that

further investigation is required into the compilation and eligibility of any clinical

leadership programme. For example, a programme for nurses/midwives who

have been in practice 10 years and less, another programme for nurses/midwives

who have been in practice more than 10 years.

6. Evidence points to the availability of a variety of leadership models (such as

authentic, transformational or transactional). It is recommended that, in

consultation with the Nursing Directorate and Professional Development Unit,

agreement is reached as to the preferred model(s) a leadership training

programme is based upon. It is further recommended that the content of any

programme reflect that particular model(s).

7. The literature details the need for mentorship when building leadership capacity

within clinical areas. Although Pebbles and Kohatu had been considered to offer

a form of mentorship to participants, this was not borne out by the research. It is

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recommended that all future programmes require clinical wards/units to provide

formal mentorship for each leadership participants. In this event, mentorship

training would be required of potential mentors.

8. While data indicated reasonable support for the nomenclature Pebbles to

continue, it is recommended that further discussion is required in order to decide

whether a name clearly identifying the programme as a nursing/midwifery clinical

leadership programme be used instead.

9. Following comment from Te Puna Oranga in regard to the name Kohatu, it is

recommended that further consultation be undertaken on this matter.

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PLURALISTIC EVALUATION OF THE PEBBLES AND KOHATU

NURSING AND MIDWIFERY LEADERSHIP PROGRAMMES

EVALUATION REPORT

November 2011

1. INTRODUCTION This research evaluated the Waikato District Health Board’s (WDHB) Professional

Development Unit’s (PDU) nursing and midwifery leadership programmes. These

programmes involve two separate groups of participants: non-Maori (Pebbles) and Maori

(Kohatu) nurses and midwives. Five Pebbles programmes have been completed occurring

between 2007 and 2010. Two Kohatu programmes have been completed; one in 2008 and a

second in 2010. The research has focused on evaluating the impact and influence these

programmes have had on participants in relation to their individual nursing and midwifery

practice. It also considered the contribution the Pebbles and Kohatu programmes have had

on the general nursing and midwifery environment within the Waikato District Health Board.

Since the inception of the programmes the acquisition of leadership skills has become an

important focus, particularly within the clinical environment, and the evaluation therefore

sought to find out if this aspect had caused participants to re-evaluate their career aspirations

and if so, how this manifested itself.

The report presents an overview of the Pebbles and Kohatu programmes including their

structure and ideological and methodological underpinnings which have to a large extent

been informed by Practice Development (PD). A review of nursing leadership literature is

presented and the research methodology is discussed along with the findings.

Recommendations regarding continuation of the Pebbles and Kohatu programmes are made

at the conclusion of this report.

2. BACKGROUND i) Generic Leadership Training, Waikato District Health Board Within the Waikato District Health Board generic leadership programmes are available. In

2002 Learning and Development, which is aligned with the DHB’s Human Resources

Department, implemented the first of a number of programmes. The initial programme was

called ‘Healthy Futures’ and ran for two years. In 2005 the national body which oversaw

District Health Boards throughout New Zealand (DHBNZ) put together a leadership

framework aimed at clinical and non-clinical staff working within the health sector. The

Leadership and Management Programme (LAMP) ran over an eight month period and

focused on management skills as well as the establishment of networks across the health

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sector. The programme covered a range of topics including strategic thinking and planning,

creative thinking, problem-solving, facilitation skills and emotional intelligence. One

requirement of the course saw participants involved in a project which included a coaching

component2.

Waikato DHB aligned its leadership programme with competencies as suggested in DHBNZ’s

leadership framework. Importantly, these competencies are now reflected within position

descriptions and have a direct bearing on staff performance reviews. The competences are

described3 as:

Contribution • Models and adheres to the DHB’s values, vision, and code of conduct

• Provides safe and quality service delivery for patients/clients/customers

• Completes work within required timeframes Self and others • Seeks opportunities to continuously improve, and works to learn

and grow Relationships • Maintains effective relationships patients/clients/

consumers, and with peers and the employer, and encourages collaboration and effective group interactions

Getting results • Is open to learning new things and picks up technical skills in a reasonable timeframe

• Is action orientated and undertakes duties with professionalism and enthusiasm

Change • Looks for opportunities to improve processes and uses logic and analysis to review information in order to make sound decisions

The Leadership in Practice Programme run by Learning and Development has been in place

since 2006 and is available to individuals holding leadership and management positions

within the Midland region (Bay of Plenty, Lakes, Tairawhiti, Taranaki and Waikato District

Health Boards). Nurses and midwives in leadership roles within clinical areas (such as nurse

and midwifery educators, clinical nurse specialists and associate/charge nurse managers) as

well as nurses and midwives in management roles, such as a service manager or nurse

manager of a cluster (eg: surgery or medicine) are often given priority when it comes to the

selection process. The Leadership in Practice Programme takes place over a five month

period (one day per month) with a follow-up day several months after the initial workshops.

The programme content comprises both theoretical and practical aspects of leadership,

including sessions on values, prioritisation, team dynamics and team-building, succession

planning and delegation4. The programme does not cover what can be termed ‘technical

managerial skills’ such as ward/unit budgets or rosters.

2 http://www.dhbnz.org.nz/Site/Future_Workforce/LAMP/MAP/Default.aspx (retrieved 02.02.11). 3 From a position description for a Waikato DHB registered nurse (December 2010) 4 See Leadership in Practice Programme February to June 2011: Midland leadership (www.mindlandleadership.co.nz).

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Within the clinical and organisational environment there is of course a marked difference

between being a nurse or midwife considered to have leadership potential to being a nurse or

midwife in a leadership role. The Nurse Co-ordinators Practice Development (NCPDs)

working within the Nursing Research Development Unit5 (NRDU) recognised that in many

cases nurses and midwives either applied for or were seconded into leadership roles prior to

any formal leadership training. In order to address this and other issues (outlined below), the

Pebbles and Kohatu programmes were planned and implemented. While leadership was not

initially the programmes’ raison d’etre, over time it has evolved as the main focus.

ii) Pebbles and Kohatu Programmes The Pebbles and Kohatu programmes were set up in 2007 by the Nurse Co-ordinators

Practice Development. The programmes were seen as a means of contributing to the

development of nurses and midwives working within clinical environments encompassing

acute and community services. The programmes were designed to cater for nurses and

midwives who were working at the ‘coal-face’ of clinical care as opposed to those who were

working in middle or upper management roles. The stated purpose of these programmes

related to “enhancing personal and professional potential” in order to:

• Enable nurses and midwives to develop skills to lead and manage change

• Support nurses and midwives to prepare for future leadership roles

• Support workforce and succession planning within the WDHB6

Other purposes related to more values-based qualities such as personal enrichment and

‘celebrating’ nursing and midwifery as professions.

The programmes themselves were described in the course handbook as …a facilitated journey of self-discovery, supported by group work, reflective processes and coaching…methods used will include critical companionship, mentoring, supervision, facilitation, action learning and coaching. Participants will be engaging in a journey using the Practice Development objectives of enlightenment, empowerment and emancipation7.

The Pebbles programme was originally constructed as a pilot utilising Practice Development

methodologies. The NCPDs had already introduced PD into a number of specific wards and

units and during this process they recognised that a number of gaps existed in regard to

progressing nursing and midwifery careers. One facilitator described what they saw and how

they defined the ‘gap’:

5 The NRDU ceased its existence in 2009 and the personnel were incorporated into the DHB’s nursing Professional Development Unit (PDU). The PDU is the education and professional development hub for nursing and midwifery and contains the PDRP and HWNZ advisors, New Entry To Practice (NETP), Nurse Educator Professional Development and Practice Development roles as well as the Research Fellow. The Unit is headed by a Clinical Nurse Director. 6 NRDU Pebbles 2008 Programme: p.1. 7 NRDU Pebbles 2008 Programme: p.2.

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…we actually drew up a model which was like bricks in a wall and we looked at where a nurse could perhaps plot their career and when we looked at that there was a hole in the wall…how do you get into the leadership programmes that are currently offered from just being a talented person working in the environment, because you almost have to be in a role that you are not fit for before you get access to that. There are great opportunities for people in the Learning and Development Programme but they weren’t accessible by a staff nurse or a clinical midwife on the floor [and we were saying] there is a gap and we could fill it. [Nurse co-ordinator PD]

Another aspect to the setting up of the programme was a perceived need to develop and/or

mentor clinical nurses and midwives who one facilitator described as “little stars who were

quietly influential but nobody really noticed them”. Nine nurses participated in the pilot and

were ‘shoulder-tapped’ for the programme. This was because in the early stage no criteria for

inclusion had been drawn up. However, participants were not self-selecting; the facilitators

contacted the Charge Nurse Manager (CNM) where each potential participant worked and

asked if they would allow the nurse to attend. CNMs also had to agree to each participant

being rostered off clinical duty one day a month for six months in order that they could attend

the Pebbles Programme. Potential participants were given minimal information prior to the

first Pebbles session and the facilitators described how it was conceivable that some

participants might have thought they were “in trouble” or “they’d been sent to us to be fixed!”

Following the initial pilot further participants were nominated by CNMs.

It is apparent though that the focus of the initial pilot was not solely on leadership. The PD

facilitators stated …we tossed a lot of words around and the word that we liked most was enrichment. That met our meaning most clearly…it was about taking people who were already capable and good, offering them a level of enrichment, of experience and ideas and thinking and seeing…with no obligation on them to do anything particular with it…we would put in an intervention and see what would happen.

Although the concept of personal enrichment and learning remained an important component

of the Pebbles and Kohatu programmes, it became increasingly evident that the organisation

also required nursing and midwifery staff to be equipped with leadership skills. The reasons

for this are multifarious. From an etic perspective - an ageing workforce population, the

portability of nursing skills (in the case of New Zealand – nurses being particularly attracted to

working in Australia), together with a fiscally constrained health sector meant the registered

nursing resource has become depleted at both national and international levels (Carryer,

Diers and Wilson 2010; Davidson, Elliott and Daly 2006; Goudreau and Hardy 2006;

McCloskey and Diers 2005; McKenna 2005). The need for strong and dynamic nursing

leadership is therefore pivotal in order to not only “shape and direct clinical practice to ensure

optimal patient outcomes” but also to “lead and direct health care service and clinical practice

development” (Davidson, Elliott and Daly 2006:180).

At its Clinical Leadership Forum held in June 2010, Health Workforce New Zealand (HWNZ)

released a paper which refers to the need to ‘grow’ leadership capability within the health

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sector. It describes the importance of clinical leadership and creating learning opportunities

for “leadership development from novice to expert…[together with] a wider culture and

environment that supports and nurtures leaders” 8. This focus on leadership is also evident in

the Waikato District Health Board’s Nursing Strategic Plan 2007-20119 which identifies the

cultivation of nursing leadership and management capacity and capability as one of its key

objectives. The Plan also refers to the use of PD in relation to supporting workforce

development processes and the Pebbles and Kohatu Leadership programmes are an

example of this objective being put into practice.

iii) Pebbles and Kohatu Programme Content The content of the Pebbles and Kohatu programmes has evolved since their inception in 2007

and 2008 respectively. However, each programme has comprised six sessions, one per

month, and covers a full working day. At the end of each session participants were given a

homework task. For example, they were required to critically appraise a nursing journal article

or asked to search a website (such as the Health and Disability Commission) and prepare an

item of interest to share with colleagues at a following session. A workshop with the Waikato

DHB librarians also formed part of the programme content with participants receiving library

computer training along with other support or tuition as required.

Integral to the programmes have been the following:

• Practice Development tools/models (McLADU, BEET, DEEP, WADULA, CREAM,

Heart of the Practice10)

• Professional and personal reflection concepts

• A variety of academic literature (for example, scholarly articles on nursing

leadership)

• Information regarding academic pathways

• Information technology (websites; library databases)

• Health literacy including learning about the Waikato District Health Board

organisation (such as the Nursing Directorate strategy; the Maori Health strategy

and structural changes within WDHB) as well as national health policies

• Meeting people within the Waikato DHB’s nursing, midwifery and organisational

hierarchies

• Opportunities to reflect on practice and articulate experiences to fellow

participants

• Presentation skills

8 http://www.healthworkforce.govt.nz/our-work/clinical-leadership (retrieved 15/06/11) 9 http://ourintranet/NR/rdonlyres/08E2596B-B4B7-4609-BD4B-04D6C216CC6C/0/StrategicPlanNursing.pdf 10 Details relating to some of these tools/models are contained in Appendices I, II, III, IV, V.

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Each session had a particular focus:

• Session One – Introduction (personnel and PD concepts)

• Session Two – Sourcing and working with knowledge

• Session Three – Networking effectively

• Session Four – Exploring professional pathways

• Session Five – Working in context (how to use PD within the workplace

environment)

• Session Six – Sharing knowledge

In 2009 the focus of the Pebbles and Kohatu Programmes altered in order to account for the

competencies outlined in Carol Huston’s (2008) article (discussed in more detail below) as

well as to align with the key strategies adopted by the Professional Development Unit (PDU):

1. Strengthen workforce capacity, capability and readiness

2. Promote lifelong learning and future focused practice development

3. Use evidence based practice to ensure patient safety and best outcomes11

Underlying these strategies is the requirement to develop a succession plan in relation to the

nursing and midwifery workforce (McCallin, Bamford-Wade and Frankson 2009), as well as

preparation of nurses and midwives who are able to both lead and manage required changes.

The programmes comprised skill development workshops (critical thinking skills, innovative

practice, project management knowledge, post-graduate education opportunities and career

pathways); strategic planning including organisational structures and management dynamics;

exposure to information about the political, social and environmental factors governing health

policies and direction; and information about current trends and issues affecting Waikato DHB

clinical environments. Discussion and explanation of Practice Development principles and

concepts was also integral to the overall programmes.12.

From the inception of the programmes each participant was required to make a formal

presentation to their group on a topic relating to either an aspect of their personal lives they

wanted to share (such as a particular hobby or interest) or from their clinical practice.

However, in the most recent programmes, participant presentations have solely focused on

clinical environments/practice and areas of interest. As well as the ‘formal’ components of the

programmes, participants were given an opportunity at the start of each session to discuss

‘the month that was’; a vignette relating to personal or clinical experiences.

11 Growing Our Future, Pebbles Programme Outline 2009-2010. 12 Growing Our Future, Pebbles Programme Outline 2009-2010.

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iv) The Role of Practice Development Practice Development principles influenced both the development and delivery of the

programme and Practice Development processes, tools and concepts formed part of the

content of the programme.

When Pebbles and Kohatu were developed, Practice Development (PD) was defined as: [A] continuous process of improvement towards increased effectiveness in patient centred care. This is brought about by helping healthcare teams to develop their knowledge and skills and to transform the culture and context of care. It is enabled and supported by facilitators committed to the systematic, rigorous continuous processes of emancipatory change that reflect the perspectives of service users (Garbett and McCormack, 2002).

The purpose of PD was, and is, to improve patient care and service delivery. As well as this,

PD aims to empower practitioners to develop their individual and collective service, and foster

and develop a transformational culture (Manley and McCormack, 2002). The belief is that it is

only through the development of a person-centred organisational culture (a culture that values

the personhood of all people, including staff), that true patient-centred care can flourish.

PD originated in the UK and Ireland and whilst the Pebbles and Kohatu programmes can be

seen as PD based, they were also built upon a particular view of PD that was influenced by

the culture and the context in which it took place. The programmes deliberately set out to

value those elements of the New Zealand cultural context which build engagement and

relationships as well as find practical solutions to problems. For example, the Treaty of

Waitangi principles of partnership, participation and protection are congruent with PD ways of

working through collaboration, participation and inclusion. In addition, PD in New Zealand has

been influenced by the pragmatics of a small nation which has to do a lot with a little. Indeed it

has been noted that PD in New Zealand has …been subtly influenced by the Number 8 wire view … to produce practical, simple and effective tools and processes for practice development, which … have included simple tools and processes for developing engagement, undertaking collaborative problem solving or “puzzling… (Walsh and Moss, 2007).

Tools such as McLADU, BEET, DEEP, WADULA, CREAM, and PD concepts such as Heart

of the Practice and Puzzling are testimony to these practical but values based ways of

working.

It is apparent that working in person-centred ways that embody collaboration, participation

and inclusion; building on strengths and what works; and finding practical solutions to

problems, have underpinned the theoretical background and practical application of the

Pebbles and Kohatu programmes.

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3. LITERATURE REVIEW The literature review comprises material relevant to nursing leadership programmes

(information relating to midwifery has not been specifically included but is inferred throughout

this report). The review has been compiled throughout the period of the research and also

expanded upon once themes were identified following analysis of the findings. The literature

was sourced from published researched studies between the years 2000-2010 and

predominantly from nursing journals. However, social science, health research and

management literature has also been incorporated as appropriate. The review is organised

into three sections. Working as a nurse or midwife, whether within a clinical, management or

academic environment, does not occur within a vacuum divorced from the wider socio-

political-economic milieu. Therefore the first part of this literature review canvasses the impact

social change has had on the nursing profession over the past two decades and the affect

this has had on nurse leadership roles. The second section presents an overview of what is

meant by nursing leadership while the third section details a range of literature setting out

methods to prepare nurses and midwives for clinical leadership roles.

i) Nursing in the 21st Century In New Zealand and other developed countries, the delivery of health care is under significant

pressure due to an increasing ageing population, a rise in chronic illness rates and other

diseases such as cancer, higher expectations of medical interventions by the general public

and a constrained fiscal environment. A manifestation of this situation can be seen in the

plethora of ‘reforms’ which the health sector, both in New Zealand and internationally, have

been subjected to over the past two decades. The consequences of reforms and

restructuring of the health care sector on the nursing profession have been profound:

significant reductions in registered nursing FTE, decreased job satisfaction levels, increased

turnover rates, fragmentation of health care team relationships and negative effects on nurses

physical and psychological well-being (Aiken, Clarke, Sloane, Sochalski et al 2001; Carvalho

and Santiago 2009; Cummings 2006; Oulton 2006).

From the New Zealand perspective, reforms which began in the mid-1980s and are still

continuing today have seen major changes in the way health care is provided. Underpinning

these reforms was the uptake by governments and policy makers, both in New Zealand and

internationally, of the ideological framework known as New Public Management (NPM). To

paraphrase Carvalho and Santiago (2009:609), NPM at the macro level saw the introduction

of a market-based ethos which promoted a competitive environment encouraging a

commodified approach to health care services. At the micro level, that is – within the public

health sector – new governance and managerial models were introduced. In New Zealand,

these ideologies were demonstrated through the splitting of purchaser-provider services;

contract based deliverables, business-focused structures with General Managers/Chief

Executive Officers at the helm; regional and national purchasing agencies; and, with particular

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implication for the nursing profession, implementation of a managerial ethos which resulted in

the decimation of clinical leadership roles in favour of non-clinical managers (Fougere 2001;

Gauld 2000; Hornblow 1997; Sage, Degeling, Coyle, Perkins et al 2001).

In tandem with reforms affecting the health care arena, the employment/labour relations

sector was also significantly altered during the 1990s. The Employment Contracts Act (ECA)

(1991) aimed to increase competition within the labour market by dis-establishing and

fragmenting national awards (Webber 2003). Nurses were profoundly affected by these

changes which saw the removal of penal rate payments as well as changes to pay and

condition frameworks, allowance and overtime provisions (Webber 2003). McCloskey and

Diers refer to these neo-liberal reforms as “re-engineering” and note that “nurses in

management positions were replaced with non-nurse business managers…reduc[ing] hospital

nursing staff and dismantel[ing] nursing leadership structures within hospitals” (2005:1141).

Responsibility for nursing budgets was lost to non-clinical managers and senior nurse

positions were replaced by new graduates (McCloskey and Diers 2005). As Gower, Finlayson

and Turnbull (2003) argue, the loss of these roles cannot be under-estimated in regard to the

professional development of younger nurses and the nursing profession as a whole.

Another facet which cannot be overlooked is the link between nursing care and patient

outcomes. The nursing voice and nursing presence became somewhat muted during the

reform process and yet it is an essential element in regard to improving patient outcomes and

ensuring quality care (McCloskey and Diers 2005). As Carryer, Diers and Wilson’s research

indicates,

policy changes in the 1990s adversely affected those patient outcomes that are especially sensitive to nursing care” (for example, “central nervous system complications, decubitus ulcers, sepsis, urinary tract infections, physiological and metabolic derangement, pulmonary failure and surgical wound infections (2010:276).

While it could be argued that the pace of health sector reform in New Zealand has

decelerated, changes are ongoing. Regionalisation of core services, the reinstitution of the

Enrolled Nurse role, plus increasing use of Health Care Assistants in the acute care setting

are examples of some of these. Nurse leadership roles such as Directors of Nursing have

been re-established, as have nurse-manager positions. However, the ability to control the

nursing budget remains, to a large extent, outside the parameters of these roles (Carryer,

Diers and Wilson 2010).

In order to advocate for patient quality of care determinants and nursing workforce issues

(Aiken, Clarke, Sloane, Sochalski et al 2001), the nursing profession needs to concentrate on

developing leadership succession programmes (McCallin, Bamford-Wade and Frankson

2009). Defining what leadership is and how to enact it is discussed in the following two

sections.

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ii) Nurse Leadership

Michael Cook (2001a) argues that the success or otherwise of patient care initiatives is

largely dependent on the quality and ability of clinical nurse leaders. Intrinsic to this is the

notion that leadership is derived more from an attitudinal perspective which informs behaviour

as opposed to a privileging of particular skills and tasks (West-Burnham 1997 cited in Cook

2001a:48).

Defining clinical leadership is somewhat problematic because the terms ‘leadership’ and

‘management’ are often used interchangeably in much of the nursing literature (Cook 2001a;

Stanley 2008). For example, research undertaken in Ireland aimed to discover the clinical

leadership development needs of nurses reported that participants had difficulty in articulating

what clinical leadership comprised but in general agreed that “clinical expertise, experience

and credibility” were important components (Casey, McNamara, Fealy and Geraghty

2011:1507). Cook (2001b:33, our emphasis) argues that “the most influential people, in terms

of improving direct care provision, are those that directly deliver nursing care”. Keeping this in

mind, the literature reviewed for this study focuses on leadership within clinical environments;

ie: where direct nurse-patient interactions occur. A range of pragmatic and metaphysical

qualities are evident. For example, nurses who are patient-focused, critical thinkers, clinically

competent and confident utilising evidence-based practice, able to initiate and manage

change, able to understand budgets and financial constraints as well as remaining cognisant

of the wider social and political landscape and its influence on health policy and direction are

considered to possess leadership attributes (Bretschnider, Glenn-West, Green-Smolenski and

Richardson 2010; Casey, McNamara, Fealy and Geraghty 2010; Cook, 2001a; Davidson,

Elliott and Daly 2006). Other leadership skills detailed include goal-setting, the ability to

motivate others and being supportive of colleagues (Davidson, Elliott and Daly 2006).

David Stanley’s views of leadership are more metaphysical in origin and he argues that

attributes which are ‘values-based’ or ‘congruent’ are important when considering leadership

characteristics. These characteristics include: an approachable and open manner; role

modelling values and beliefs; effective communication skills; decision-making ability and

‘visibility’ (Stanley 2008). In a study examining nursing leadership within an intensive care

unit in Australia, “incivility” between members of the wider health care team unsurprisingly

resulted in a less than productive care environment for patients (Sorensen, Iedema and

Severinsson 2008). One conclusion from this study was the need for nurses to provide

leadership by way of developing professional advocacy skills in order that they confront and

address what the authors term the “moral injustices” experienced by patients and nursing

staff. As with Stanley’s (2008) paper mentioned above, a moral- and or values-based

component to leadership is considered important. Another leadership style which is also

values-based is that of authentic leadership. This type of leadership incorporates what is

known as ‘soft skills’: “[the] ability [for leaders] to understand their own purpose, practice solid

values, lead with heart, establish enduring relationships, and practice self-discipline” (George,

18

2003 cited in Shirey 2006:260). Maria Shirey points to the lack of empirical evidence

surrounding this leadership style but argues that in the wake of behaviours seen in the

corporate and banking sectors in recent times, a leadership style incorporating ‘soft skills’

appears to have merit for organisations as a whole, as well as “at the front line or the point of

care” (Shirey 2006:266). The soft skill and values-based approaches have synergy with

Practice Development ideologies.

In her paper outlining competencies required of nurse leaders by 2020, Carol Huston (2008)

highlights the unpredictable and increasingly complex nature of both the corporate and

health-care sectors. Huston argues that nurses will require preparation for this environment

through formal education programmes as well as informal learning opportunities and lists

eight competencies she considers will be required. These are:

1. A global or ‘big-picture’ perspective of healthcare and professional nursing issues

2. Technology skills that factor in the increasingly mobile nature of health care provision.

3. Evidence-based practice

4. Creativity to ensure organisations provide quality and safe health care that impacts

positively on patients and health care workers

5. An understanding of political processes and utilising this knowledge to advocate

within this environment when required

6. Collaborative and team-building skills

7. Congruent leadership

8. Change management skills

The literature also points out nurses require opportunities to learn and practice leadership

capabilities because to date these have generally not been considered an intrinsic part of a

nursing ‘skill-set’ (Johnson, Hong, Groth and Parker 2010).

Barriers to leadership development include budgetary and release time constraints as well as

non-nurse management looking for short-term interventions to “fix a problem” as opposed to

committing organisations to “ongoing training and professional development” (O’Neil,

Morjikian, Cherner et al 2008:182). While it is acknowledged that learning and development

opportunities ‘cost’ organisations13, the other side of the equation is that investing in staff

reaps benefits in regard to succession planning, improved attitudes to work and performance

and staff retention and recruitment rates (Cook 2001a; Johnson, Hong, Groth and Parker

2010; Meehan and Green 2002; O’Neil, Morjikian, Cherner et al 2008).

13 For example, RN salaries as per the NZNO MECA: Grade 4 $55,220 per annum, Grade 5 $61,362.00. In regard to a Grade 4 salary, there are approximately 229 working days per calendar year which equates to an RN being paid at $241/day. Therefore six days of Pebbles/Kohatu = $1446 per participant in time release.( It should also be noted that per Nursing Council directive, all RNs must receive 60 hours of education every three years.)

19

iii) Leadership preparation The development of leadership skills is not, of course, peculiar to nursing or health-care

environments in general. Gaining insight from other disciplines is necessary (Meehan and

Green 2002) especially given the lack of empirical evidence relating to nursing leadership

programmes (Kerfoot 2006). Successful learning and development programmes can be by

way of either internal or external providers (O’Neil, Morjikian, Cherner et al 2008). Cook

(2001a) and Morgan (2005) suggest that leadership preparation should be introduced early in

nurses’ careers. Cook (2001a) and Meehan and Green (2002) also allude to the use of,

mentorship, ‘reflective partnerships’ and clinical supervision as a means of assisting with the

growth, development and implementation of leadership skills within the practice setting.

According to Meehan and Green (2002), careful planning is required in order to ensure that

organisations develop leadership capabilities. Abrams (2002) (cited in Meehan and Green

2002:7) describes a number of steps organisations need to consider when involved in

succession planning:

1. Creating a leadership profile

2. Identifying leadership candidates

3. Creating a leadership development plan

4. Providing systematic feedback to candidates

5. Ensuring that any plan remains relevant. This is especially important given the pace

and nature of change within the health-care sector

Meehan and Green’s (2002) paper outlined the development of leadership capacity

undertaken at North Staffordshire Hospital NHS Trust. Identifying suitable candidates proved

challenging and the selection process mirrors that of the Pebbles and Kohatu programmes

with senior nursing and midwifery managers nominating participants. Importantly, candidates

were made aware that participation in the programme did not guarantee a senior role and it

was acknowledged that potentially staff might be lost to other organisations in the future. The

training programme set up by this Trust was facilitated by managers, clinicians and external

consultants and comprised “problem based learning, coaching, formal teaching sessions,

project work, self-directed learning, job shadowing and experiential learning opportunities”

(Meehan and Green 2002:8).

Another NHS Trust (West Hertfordshire Hospitals) also implemented a leadership

development programme. The structure of this programme was similar to Pebbles and Kohatu

with participants attending one day a week for a period of six months. Four performance

criteria informed the programme: practice development, management, leadership and clinical

and professional development. Topics included clinical risk management, business strategy

and planning, change management and leadership (Morgan 2005). Increasing participants’

political awareness by exposure to people of influence within the Trust was also a component

20

of the programme (Morgan 2005). A facilitative approach to learning was adopted and one

aspect of this related to a learning contract drawn up between each programme participant

and his/her manager. Evaluating the results was also considered an intrinsic part of this

development process and was done by way of the learning contract previously mentioned as

well as by way of an approach developed by Pawson and Tilley (1997) (cited in Morgan

2005:29) which considerd aspects such as programme methodologies and content,

acquisition of knowledge and skills, and staff turnover rates.

Richard Redman endorses the need for evidence-based nurse leadership programmes,

especially in regard to improving the quality and safety of patient care. He points to the need

for health care organisations to engage in systematic planning processes which “anticipat[e]

leadership needs” (2006:292) and once this has been established, develop requisite

programmes/education to achieve what is required. Redman points to the need for nursing

leadership across health care organisations: clinical units and middle and senior management

levels. Research indicates that leadership programmes positively influence both recruitment

and retention staffing levels (MacDonald and Ling 2002; Morgan 2005, Oulton, 2006,

Sherman and Pross 2010)

In regard to the development of leadership succession planning Redman (2006:293) suggests

the following:

1. Assessment of what positions will be required within the organisation as well as

ascertaining what skills and qualities individuals who fill these posts will need.

2. Assessment of individuals currently working within the organisation in relation to their

potential leadership capabilities.

3. “A well designed leadership development process” which will ensure there are a

number of individuals who will be available to take-up leadership positions as they

become available.

Mary Casey et al (2010:1502) argue that although nurses and midwives “are expected to fulfil

a leadership role at all levels…efforts to strategically support them are often unfocused”. A

1995 report14 carried out to report on nursing leadership within the NHS described a number

of strategies required to identify and prepare nurses for leadership positions. These included:

1. Development of clearly defined career pathways.

2. Exposure to strategic development in order that participants are able to consider the

‘big picture’.

3. Early identification of nurses with leadership potential and subsequent education and

experiences which in effect ‘grooms’ them for future roles.

14 Newchurch and Company and the NHS Executive (1995). Cited in Cook, M. (2001). The renaissance of clinical leadership. International Nursing Review 48,38-46:40.

21

4. Opportunities to network and mentor both within and outside their

institutions/organisations.

As outlined above, the healthcare environment has been subjected to continual restructuring

since the 1980s. Greta Cumming’s research (2006) revealed that the style of leadership

adopted by nursing leaders is integral to the receptiveness, or otherwise, of nurses to the

restructuring process and she articulates these styles as ‘resonant’ or ‘dissonant’. Resonant

leadership, as proposed by Goleman, Boyatzis and McKee (2003), manifests itself through

positivity, empathy, energy and teamwork. On the other hand, dissonant leadership

comprises apathy, negativity, lack of empathy and self-centredness (ibid: 2003).

Unsurprisingly perhaps, Cumming’s found that: Despite experiencing relatively similar hospital restructuring events, nurses who worked for resonant leaders experienced significantly fewer negative effects of hospital restructuring than did those who worked for dissonant leaders….These findings have implications for recruitment, training, and accountability expectations of hospital leaders and for developing practice environments, health and retention of nurses, and ultimately patient care outcomes (2006:325).

In essence, Cumming (2006:327) is suggesting that health care environments which have

been, and continue to be, subjected to changing political and management mandates are

better placed to meet patient needs when they adopt leadership styles predicated on

collaboration and partnership.

4. EVALUATION OF PEBBLES AND KOHATU PROGRAMMES Karlene Kerfoot argues that nursing has fallen short in regard to providing evidence-based

rationale for its management and leadership practices. She states there is a need for

“evidence-based leadership rather than opinion-based leadership” (2006: 373-374). The

Professional Development Unit recognised the need for a formal evaluation of the Pebbles

and Kohatu programmes and therefore commissioned this research. The research team

comprised six members whose tasks ranged from advisory roles to data collection and

analysis:

Dr Philippa Miskelly. Philippa is the Principal Investigator (PI) for this research. She is

an anthropologist and holds a joint Research Fellow appointment with the Waikato

District Health Board and the School of Nursing, University of Auckland.

Mrs Lindsay Duncan. Lindsay is a Nurse Co-ordinator Practice Development. She

has co-ordinated and facilitated a wide variety of Practice Development initiatives

within the Waikato District Health Board over the past eight years, including the

Pebbles and Kohatu Programmes. Previous to this she worked as an accredited

diabetes nurse specialist.

Professor Ken Walsh is the inaugural Professor of Nursing Practice Development, a

joint appointment between the School of Nursing, Midwifery and Indigenous Health

and the Illawarra Shoalhaven Local Health District, Woolongong, Australia. Ken

previously held the post of inaugural Professor of Nursing Practice Development at

22

the Waikato District Health Board, a joint appointment with the School of Nursing,

Midwifery and Health, University of Victoria, Wellington.

Dr Cheryle Moss is Associate Professor Nursing, Research and Practice

Development in the School of Nursing and Midwifery, Monash University, Melbourne,

Australia. Cheryle also holds the school portfolio as Director (Community

Engagement). Cheryle was involved with Practice Development initiatives at the

Waikato District Health Board when she was employed at the School of Nursing,

Midwifery and Health, University of Victoria, Wellington.

Professor Wendy Cross is Head of School, School of Nursing and Midwifery, Monash

University, Melbourne. Wendy’s research interests include practice development and

workplace learning.

Dr Kay McCauley is a Senior Lecturer at the School of Nursing and Midwifery,

Monash University, Melbourne. Kay’s research interests include practice

development and action learning.

This study was conducted as an evaluation involving a number of different research methods.

In the following section the methodological rationale relating to the research design is

explained along with the methods utilised and the obtaining of ethical approval. The study’s

limitations are also outlined. Detailed analysis of data follows.

i) Research Process Evaluation research “seeks to evaluate whether a particular programme of activity is

achieving its stated ends” (May 1997:183) and is generally utilised to seek feedback about the

usefulness or otherwise of a particular intervention (in this case, the Pebbles and Kohatu

programmes). However, it is often notoriously difficult to quantify what ‘success’ or

‘achievement’ means, especially within the health care environment, because of the numbers

of stakeholders involved and the variation of their opinions and perspectives (Nolan and Grant

1993). Other aspects which add to the complexity of undertaking an evaluation are ill-defined

programme aims and objectives (Nolan and Grant 1993) as well as political and social

influences on organisational environments which can be reflected through the uptake (or not)

of recommendations. Despite these potential obstacles, a pluralistic or mixed-methods

approach to this evaluation was considered appropriate because …[it] starts from the premise that criteria for judging the success of an innovation are largely situational and open to different interpretation by various stakeholders. The evaluator’s task is first to identify the major stakeholders and then to elicit and compare their views of the aims and outcomes of the innovation and to use their subjective perceptions as the major determinant of ‘success’ (Gerrish 2001:111-112).

This study utilised the collection of quantitative and qualitative data. While positivistic

methodologies are well understood and accepted within the health sector, scepticism

surrounding the use of qualitative methodologies remains because of the perceived subjective

and interpretative nature of analysis as well as researcher bias. With this in mind, Atkinson

23

(1997 cited in Horsburgh 2003) argues for the need to contextualise narrative data in order to

provide meaningful analysis, and to this end the findings and recommendations in this report

reflect the wider environment the study was conducted within.

ii) Research Question The main focus of this research related to the following question: What impact and influence have the Pebbles and Kohatu Programmes had on participants in relation to their individual practice at the Waikato District Health Board? This question was formed because the PDU wanted to assess the success or otherwise of

the Pebbles and Kohatu programmes to ascertain what, if any, impact and influence it had on

participants. Because the programmes were designed to support and mentor leadership

development, it was considered that tracking the career of participants would be an integral

component of the study.

iii) Research Methodology A pluralistic/mixed methods approach for the study was adopted. Quantitative data was

gathered via a questionnaire (Appendix VI) sent to all Pebbles and Kohatu participants who

had completed programmes. Information from returned questionnaires was entered into an

excel database and then transferred to SPSS for analysis (see results below).

The second phase of this study was qualitative in focus. Although qualitative methodology is

open to criticism of being interpretative and subjective, Denzin and Lincoln (2003:4-5) speak

to its advantages:

Qualitative research is a situated activity that locates the observer in the world. It consists of a set of interpretative, material practices that make the world visible. These practices transform the world. They turn the world into a series of representations....This means that qualitative researchers study things in their natural settings, attempting to make sense of them, or to interpret phenomena in terms of the meanings people bring to them.

In order to gain an understanding of what Pebbles and Kohatu meant to people involved with

the programmes, in-depth interviews with a range of participants were conducted.

Interviewing is a method which, according to Minichiello et al (1990:87) enables researchers

to “gain access to, and subsequently understand, the private interpretations of social reality

that individuals hold”. This method gives researchers flexibility and although an interview-

guide was utilised (see Appendices VII & VIII), the conversational approach adopted

throughout the interviews allows for greater in-depth examination of participants views. For

example, if either a participant or the interviewer is unsure of a point being made or an

unanticipated response is given, it is possible to ask a further question or probe a response in

order to ensure understanding is obtained.

24

Interview Participant Selection Criteria At the time this study was conducted, eighty nurses and midwives either had taken part or

were taking part in a Pebbles or Kohatu programme. The research team decided to interview

nurses and midwives who had completed these programmes, as opposed to those still

involved in a course. This provided a potential pool of sixty candidates plus the charge

nurse/midwifery managers from wards and units who had nominated nurses and midwives

since the inception of the programmes (potentially forty-three candidates).

Interviews Focus groups and individuals interviews were conducted in phase two of the data collection

process. Letters attaching an information sheet (Appendix IX) were forwarded to all potential

participants asking if they would be interested in being interviewed and a range of dates and

times were suggested. Response to this method was poor and therefore the PI contacted

potential participants either by phone or email. This improved participation rates but they were

lower than anticipated. In total, 21 participants were interviewed per the methods described

below:

3 individual Pebbles participant face-to-face interviews

1 Pebbles participant telephone interview

3 focus group Pebbles/Kohatu interviews

3 Charge Nurse/Midwife Manager individual face-to-face interviews

1 Charge Nurse Manager focus group interview

1 Pebbles/Kohatu Nurse Co-ordinator PD Focus Group

Analysis and Coding All participants were asked if they would agree to the interviews being recorded. Permission

was given by all participants although for two interviews field notes were taken instead. This

was because one interview was via telephone and the second one took place in a busy ward

office and background noise would have compromised the quality of any recording. Field

notes were typed following each of these interviews. The recorded interviews were

transcribed by an off-site typist (who had signed a confidentiality agreement). Transcripts

were then distributed to members of the research team (excluding Lindsay Duncan – see

Section iv below). The research team adopted a variety of methods in regard to analysis and

interpretation of the transcripts. Three used a coding tool which had been organised into

different sections:

1. General impressions 2. Content analysis 3. Thematic analysis

The other two researchers read and re-read the transcripts and from an overall content

analysis, a number of themes were extracted. Following telephone discussion and email

correspondence, all research team members then circulated a draft outline of major themes

25

emerging from the data. Agreement in relation to the themes was reached and are discussed

below in Section 5(ii). Emergent themes also prompted a further review of pertinent literature.

iv) Ethical Approval Ethical approval (NTY/10/06/054) for the study was granted by the Health and Disability

Ethics Committee (Northern Y), which is based in Hamilton. Part of this process involved

obtaining approval from Te Puna Oranga (Maori Health, Waikato DHB). As is usual for this

type of research, the research team were mindful of and addressed concerns relating to

transparent research processes, appropriate consent guideline procedures, and the

protection of participant anonymity. Because Lindsay Duncan has been involved in the

construction, implementation and facilitation of the Pebbles and Kohatu programmes she did

not have access to the transcriptions or take part in their analysis. This provided participants

with protection in regard to the confidentiality of their opinions. The PI conducted all interviews

and she had not been involved in the setting up or facilitation of the programmes.

5. RESEARCH FINDINGS i) Survey Results A questionnaire was drawn up and circulated to 58 Pebble and Kohatu participants. Two of

the sixty participants were overseas and not contactable and two questionnaires were

returned unopened. Of the remaining 56 participants, a response rate of 66% (N=38) was

received. The questionnaire sought demographic data as well information from 39 Likert-

Scale statements. The Likert Scale was a 7-point scale with 1= strongly disagree, 4=

undecided and 7= strongly agree. The statements were constructed under five sub-headings:

1. Pebbles/Kohatu Programme

2. Clinical Practice

3. Career

4. Leadership

5. Practice Development.

Respondents were also provided with space on the questionnaire to insert written comments

in response to the statement: ‘Any other comments you would like to make about the Pebbles

or Kohatu Programmes’.

Respondent Demographics Item Number %

Age 20-30 31-40 41-50 >50

7 12 11 8

18.4 31.6 28.9 21.1

26

Gender Female Male

36 1

97.3 2.7

Ethnicity New Zealander European Maori British Indian Asian

13 15 3 1 1 2

37.1 42.9 8.6 2.9 2.9 5.7

Training New Zealand trained Overseas trained

31 5

81.6 13.9

Qualifications PG Certificate PG Diploma Masters Certificate Adult Teaching Currently undertaking PG Study No PG Qualification

6 2 1 1 2 5

35.3 11.8 5.9 5.9 11.8 29.4

PDRP Level Achieved Prior to Pebbles/Kohatu Competent Proficient Expert Challenging PDRP level

8 13 3 1

32.0 52.0 12.0 4.0

PDRP Level Achieved Since Pebbles/Kohatu* Competent Proficient Expert Challenging PDRP level

4 13 4 4

16.0 52.0 16.0 16.0

Years since becoming an RN?

Mean = 8.13 years

NB*: Responses to the questionnaire show that 21 nurses stayed on the same PDRP level prior to and since attending Pebbles/Kohatu. Seven nurses moved either onto PDRP or up levels since being on the programme(s). It should also be noted that 9 of the respondents indicated they had either not achieved nor challenged a PDRP level. Changing Roles Twelve of the 38 respondents had changed wards/units they were working in, and nine of

these had made significant changes to their roles since undertaking Pebbles and Kohatu.

These involved:

Previous Role Current Role

District Nurse Clinical Nurse Specialist

Nurse Co-ordinator Nurse Educator

Registered Nurse Clinical Nurse Specialist

Registered Nurse Surgical Assistant

Registered Nurse RN + Tertiary Sector Tutor

Registered Nurse Clinical Research RN

Registered Nurse Clinical Nurse Manager

Registered Nurse Nurse Co-ordinator

Registered Nurse Associate Clinical Nurse Manager

27

Two other respondents indicated they had changed their roles from hospital-based to

community-based registered nurses. Three others remained as registered nurses but had

moved from the wards/units they had previously worked within.

Pebbles| Kohatu Programmes Respondents were asked questions about their views on the content and application of the

programmes. For analytical purposes we have collapsed the number of categories (from 7 to

5) to better enable trends to be noted.

Question No. Strongly

disagree/ Disagree

%

Mainly disagree

%

Undecided %

Mainly agree

%

Strongly agree/ Agree

%

1. The programme gave me an opportunity to reflect on my practice

0.0 0.0 2.6 18.4 78.9

2. I found each session of the programme useful

0.0 2.6 5.3 26.3 65.8

3. The format of the programme worked well

0.0 5.3 10.5 18.4 65.8

4. The programme was relevant to my work

0.0 0.0 18.4 21.1 60.5

5. I easily understood the ideas discussed throughout the programme

0.0 0.0 2.6 18.4 79.0

6. The presenters/guest speakers provided worthwhile information

0.0 0.0 2.6 21.1 76.3

7. I was able to complete the homework tasks each month

0.0 2.6 2.6 18.4 76.3

8. I would have liked different topics included in the programme

10.5 10.5 42.1 10.5 26.3

9. The programme was what I expected

7.9 5.3 28.9 39.4 18.4

10. It was easy to discuss ideas with the other people attending the programme

0.0 0.0 0.0 15.8 84.2

11. The programme helped me to establish the purpose of my work

2.6 2.6 18.4 15.8 60.5

12. I clearly understand what evidence-based knowledge means in relation to my work

0.0 0.0 5.3 7.9 86.8

13. At times I felt it was difficult to express my opinions within the group

60.5 23.7 0.0 5.3 10.5

14. Meeting nurse leaders during the programme has provided me with a better understanding of their roles and responsibilities

0.0 0.0 7.9 21.0 71.0

15. The programme helped me find a mentor

21.0 21.1 36.8 10.5 10.5

16. The programme provided me with access to professional support

13.2 10.5 26.3 50.0

28

Results The programmes received strongly positive feedback. Nearly all participants (n=37/38)

reported each session as useful, easily understood, provided relevant information as well as

opportunities to reflect upon their practice. Thirty-one reported the format worked well, and 32

found the programme relevant to their work. There was universal agreement that it was easy

to discuss ideas with other participants and 32/38 felt comfortable expressing opinions within

the group. There was a diversity of views about whether the programmes were as expected

and whether other topics should be included. It is interesting to note that the majority of

respondents strongly indicated they had gained a better understanding of the roles and

responsibilities of nurse leaders and this is discussed in more detail on below. However, an

important aspect revealed in the data is that the majority of respondents did not feel the

programmes had helped them develop mentoring relationships.

Clinical Practice This section of the questionnaire sought to ascertain what, if any, impact the Pebbles and

Kohatu programmes had had on respondents’ clinical practice. It also looked at respondents’

perceptions of the support they received from their clinical leader and nursing colleagues in

relation to their attendance at Pebbles/Kohatu.

Question No. Strongly Disagree/Disagree

%

Mainly disagre

e %

Undecided %

Mainly agree

%

Strongly Agree/ Agree

%

17. My CNM provided ongoing support while I was involved in the programme

7.9 5.3 10.5 21.1 55.2

18. I understood my CNM’s expectations in relation to my attendance at the programme

5.3 7.9 15.8 15.8 55.2

19. My clinical colleagues were supportive of my attendance at the programme

2.6 7.9 15.8 31.6 42.1

20. I have changed some aspects of my clinical practice since attending the programme

0.0 10.5 10.5 28.9 50.0

21. I have a better understanding of the DHB since attending the programme

2.6 0.0 10.5 28.9 57.9

22. I am now prepared to work as a preceptor

0.0 0.0 7.9 10.5 81.6

23. Since attending the programme I use the library more frequently to access information that might help with my clinical practice

15.8 18.4 7.9 26.3 31.6

24. I clearly understood the purpose of the programme

2.6 2.6 7.9 23.7 63.2

29

Results The majority of respondents indicated they were supported by their CNM while attending

Pebbles or Kohatu (N=28/38) and had received collegial support as well. Thirty out of thirty-

eight responses claimed to have changed some aspects of their clinical practice and it was

noted that twenty-two indicated they accessed the library more frequently since attending the

programmes. Thirty-three positive responses were received in relation to gaining a better

overall understanding of the District Health Board’s role. Of particular note is that thirty-five

respondents indicated they were willing to take on a preceptor role.

Career

Question No. Strongly Disagree/Disagree

%

Mainly disagre

e %

Undecided %

Mainly agree

%

Strongly Agree/ Agree

%

25. The programme helped me to stay within my clinical environment

10.5 7.9 34.2 18.4 28.9

26. The programme helped me to make changes to my work environment

7.9 13.2 23.7 55.2

27. The programme helped me to change my job/my role

13.2 5.3 28.9 21.1 31.6

28. The programme influenced me to continue with/take-up post-graduate study

13.2 13.2 15.8 21.1 36.9

Results Results show that respondents were generally positive about whether the course had

influenced them to continue with, or take-up post-graduate study (Q28). Twenty-two nurses

agreed, six were undecided and ten disagreed that the course had influenced their study

intentions.

Leadership

Question No. Strongly Disagree/Disagree

%

Mainly disagre

e %

Undecided %

Mainly agree

%

Strongly Agree/ Agree

%

29. Pebbles/Kohatu provided me with information about leadership skills

0.0 2.6 7.9 21.1 68.4

30. I now have more contact with nursing leaders

5.3 10.5 36.8 13.2 34.2

31. I now feel confident about talking with nursing leaders

0.0 0.0 23.7 26.3 50.0

32. I would like more contact with nursing leaders

2.6 7.9 23.7 28.9 36.8

30

33. I have applied/plan to apply for a nurse educator/clinical nurse leadership role

23.7 13.2 26.3 5.3 31.6

34. I have applied/plan to apply for a non-clinical nurse leadership position

40.0 21.6 18.9 8.1 2.7

35. I would like more leadership training/education

5.3 5.3 26.3 13.2 50.0

Results The majority of nurses (N=34/38) agreed that the Pebbles and Kohatu programmes had

provided them with leadership skill information, although 24 indicated they would like further

training in this area. Respondents’ appeared to consider they were more confident when

conversing with nurses in leadership roles (N=29) and 25 agreed they would like more

contact with nurses in these positions. It is of interest to note the numbers were even in

relation to those who agreed (N=14) or disagreed (N=14) about plans to apply for or had

applied for a more senior role, with 10 stating they were as yet undecided. Twenty-three

respondents signalled they did not intend to apply for a non-clinical nurse leadership position

while the remaining 14 were evenly split between being undecided (N=7) compared to

planning to apply or had applied for (N=7) such a role.

Practice Development Respondents were also asked for their views on Practice Development: understanding what

PD is; whether or not it helps within their clinical environment; whether PD has altered the

way respondents communicate with colleagues and also to what extent they engage

colleagues in discussions about PD. The results show that all respondents were positive they

understood what PD is and the majority (N=36/38) stated they find it helpful within their

clinical areas/units. Thirty-two nurses positively indicated they not only now share their

knowledge of PD with colleagues, but it also changed the way they communicate with other

nurses within their clinical environment.

ii) Stakeholder Perspectives: Focus Groups/Individual Interviews Interviews and focus groups lasted, on average, an hour. In order to protect the identity of

participants, in general reference to their clinical areas/units or other information which may

identify them has been removed. The discussion below incorporates quotations from

participants and an italic font has been used to highlight their words. Extracts from the

questionnaire have also been utilised. This data was entered into an excel database with

each respondent and his/her responses assigned a number. In this report a different sized arial

font has been used to highlight comments from this data source and they are annotated, for

example, RN21.

31

Thematic Analysis As outlined above, several readings of the transcripts revealed meaningful phrases and words

and led to a number of themes becoming apparent. These include expectations of the charge

nurse/midwife managers and Pebbles and Kohatu participants, confidence, aspiration,

resilience, ‘big picture’ and value and investment.

Expectations: CNMs The CNMs expectations of the programmes revolved around three areas:

• Development and support The CNMs generally expected the programmes to ‘grow’ leaders for the future through

developing the individual who attended. They expected the programmes to improve

confidence, further develop the skills the participant already had, help participants to

encourage and mentor others and assist individuals to show initiative: “…actively think about

how things could be done differently”. In addition some expected the programmes to provide

additional support for the ‘new’ nurses who “might benefit from coaching around becoming

future leaders”.

• Tools The CNMs expected the programmes to provide participants with tools to deal with difficult

situations such as conflict as well as tools to assist them to lead projects and innovations,

share knowledge and speak professionally and, “…increase the profile and visibility [of] all the

amazing work that nurses are engaged in all the time”.

The majority of CNMs also talked about ‘expanding the horizons’ of the nurses and midwives

nominated for the programmes. This theme is discussed in detail below under the section ‘Big

Picture’.

Expectations: RNs In contrast to the CNMs, most of the participants of the programmes expressed little in the

way of expectations and were unsure what was in store for them. Some expected the

programmes would assist with leadership development and advances in nursing practice

including research. A few participants initially thought a nomination for the programme meant

they had done something wrong.

Well, I was scared really. I thought I was in trouble. I thought they must think I need lots of help if they are sending me on a long programme like that, but that was completely unfounded. [Pebble 4]

While the majority of participants who were either interviewed or who had responded to the

questionnaire expressed positive views about Pebbles and Kohatu, there were a number of

comments relating to expectations not being realised. For example:

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I felt we required more about what makes good leaders! Skills for good leaders to succeed; ongoing processional development re. Being successful leaders; how to lead a team well. [RN24]

I did not have a clear idea what this course entailed and what the objectives were when starting. I found some aspects of the course to be waffley...would like to see more factual and concise learning...how to write protocols/incident reporting, how to perform appraisals...some kind of assessment at the end or assignment. [RN29] There was a lot of information that I didn’t feel was relevant to [my area]...I wanted to see more generic topics that are actually relevant to clinical development, clinical pathways, how management works...[Pebble 2]

My expectations were around leadership development [but] I didn’t find it as useful as I could have perhaps in terms of what was offered. I was frustrated I suppose...the approach was very laid back which was lovely but in terms of what I wanted, I think I needed a bit more...more theory, a bit more depth. [Because of the time taken with participants talking about ‘their world’ the course] didn’t become about leadership, development, management – it became about our practice...there wasn’t enough structure for me. [Pebble 6]

Participants also talked about the need for the programmes to contain information on conflict

management (when dealing with both patients and colleagues).

Confidence Nurses’ ability to contribute information as well as be involved in decision-making processes

at both clinical and professional levels is often reliant on overcoming barriers such as nursing

hierarchies, the perceived value of nursing from other members of the health care team and

institutional and corporate priorities (Sorensen, Iedema and Severinsson 2008). An attribute

which helps address these issues is confidence and it was a recurring theme during

interviews with Pebbles and Kohatu participants. Participants talked of how even the

experience of being chosen to attend Pebbles or Kohatu, as well as what they learned

throughout the duration of the programmes, had increased their confidence.

So the fact that [my CNM] who is quite unusual and disagreeable a lot of the time actually thinks that I am better than I think I am…thinks I am capable of maybe being more than I am, that really spoke a lot to me. [Pebble 3]

…it felt like a real growth process…[you could see] confidence in people, assuredness about where they were going with their careers…made me more comfortable with myself in my area of practice. [Pebble 4] It was nice for someone to be interested in you and interested in your career and try and nurture you towards your goals…it was really helpful for me. [Kohatu 1] I think it has probably given me more confidence [dealing with patients as well as clinical situations]…I love working in [clinical area] but I wouldn’t love it if I hadn’t done Pebbles. I wouldn’t have found the heart of my practice…I wouldn’t have the power to stay…I think knowing why we do things makes it better. [Midwife 1]

Questionnaire responses also indicated how Pebbles and Kohatu had increased

confidence levels: More confident in other roles now. [RN7]

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Given me confidence to apply for a new job that I previously wouldn’t have gone for. [RN21]

I’m more motivated to take on different roles and I’m more confident in my ability to communicate to a team. [RN27]

Pebbles was a great insight into what was achievable as a nurse. It gave confidence and taught skills to manage self and career setting goals. [RN28]

The literature supports these views because it appears that nurses who are given

opportunities to develop leadership skills demonstrate improved levels of confidence which

are then transferred to the practice setting. Examples of this include insight into professional

practice and the use of evidence-based practice in order to optimise patient care; in-depth

understanding of and receptiveness towards organisational priorities and change

management processes; problem-solving capabilities; and an awareness of leadership skills

and how best to utilise these within a clinical environment to improve the experience for

patients and the health care team (Cummings 2006, Dyess and Sherman 2011, Macdonald

and Ling 2002, Sherman and Pross 2010). Some of the participants interviewed described

how Pebbles had helped them to develop a professional maturity:

…actually being the grown-up, not looking to someone else…having the initiative to actually go out and be a bit more proactive, that is what Pebbles did for me..I think it was just the sense of confidence and needing to take that step forward and it was actually the discussion on management and needing to provide proof…..If I don’t know about a particular condition then I will find out through appropriate sources…what the current research is saying, taking the responsibility for myself. [Pebble 3] [Pebbles] has actually driven me to take steps, instead of wondering about certain medications, I will actually look up the research or try and find out if there are any clinical trials underway. [Pebble 2]

The CNMs who nominated RNs and midwives for the programmes talked about improved

levels of confidence being evident within the clinical environment.

She became more confident in her abilities…she was able to lead the shift when necessary…deal with difficult situations that were clinical or conflict…she took a real interest in what was happening in the ward and would put her hand up for additional portfolios. I couldn’t ask for anything more really from someone who is only a few years out of her training. [CNM1] She has been managing some really complex cases…she’s kept me in the loop…but has sort of taken over a role of supporting everyone in the team…she’ll also now speak up in meetings and have the confidence to contribute her point of view. [CNM5] One person is sort of like a mover and a shaker…at the moment she is in an acting role co-ordinating…and she has also taken on responsibility for the respiratory care team…the other staff member …certainly stepped up into the role of co-ordinating out of hours [and when I spoke to her about the programme she said she wants] to be a role model and to present herself to staff as someone they could come to. [CNM2]

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Aspiration Aligned with the theme of confidence is that of aspiration. Both these themes overlap but data

revealed that many participants had developed both insight into and confidence about their

careers. This had resulted in the uptake of post-graduate education or a change in career

direction (or both).

You certainly had clear thoughts in your head of what you could achieve because we got to meet such of lot of people who had gone places and had achieved a lot in their nursing careers so it was like ‘oh gee, if you really buckle down you can do this’…you could see what you could aspire to really…it opened your eyes. [Pebble 6] …the encouragement that was given for post-graduate study. I hadn’t felt confident to do any post-grad studies, thought it was not really for me…I’m not clever enough…but I gave it some thought and then I went and did it…I’m doing some papers towards a post-graduate diploma which is quite challenging. [Pebble 4] [The programme] got the cogs turning again. I was at a place of five years into the position, I absolutely loved it but was plodding along…and [Pebbles] re-interested me back into my profession and re-interested my thoughts into education and now I’ve got a new job, moved roles. [Pebble 2] I definitely push myself to do more since I have been on the course…I started my first paper, my certificate in March as soon as I had finished and then last year I actually was the first CNS intern they’ve employed. (Pebble 5] I guess Pebbles just gives people a bit more insight to think okay, I want to become a nurse manager and the way to do this is to start doing some post-graduate studies and start getting into some projects…I think it gives you that insight into what you want to do. [Pebble 8]

I sort of said to her that I see something in you and I think just from that and then going off and doing [Pebbles] has given her the confidence to apply [for a more senior role]. [CNM4]

Again, questionnaire responses also reflected attitudinal changes in regards to the uptake of

post-graduate education and/or career planning.

When I completed the course I completed my second post-grad paper … and now I’m challenging PDRP level proficient. [RN7]

In a nutshell I’m not so hesitant to step forwards on the career pathway now. I’m looking at post-grad study again! [RN11]

Inspired to look into post-graduate studying…amazed at how much the PG studying has helped my practice and thought processes…I may not have considered doing studying modules if I hadn’t completed Pebbles and I feel that has been instrumental in my progress over the last two years. [RN13] It has helped me get the job that I was asked to start as sub-speciality clinical nurse. [RN18] I have recently taken on a new role and am relishing every moment and I feel I may not have had the confidence to take on a teaching role without the experience of Pebbles. [RN27]

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However, the data also exposed a level of frustration amongst some participants who wanted

more in-depth information about education and career planning options:

The themes of how to go about further education and the support available were really interesting but really quite brief...the discussion about evidence-based medicine and evidence-based practice [was delivered] with a lot of information in a short space of time...I would have liked to have seen that expanded. [Pebble 3]

Resilience (and social capital) In the literature, resilience is commonly defined as the ability to recover or “bounce back” from

adversity. In this sense resilience and risk/adversity go hand-in-hand. This is not the only

sense in which we mean this term here. Rather, we are referring to resilience in the way that

some Aboriginal authors mean it; as “…more than overcoming stress and trauma, [rather]

seeing it as a natural, human capacity to navigate life well” (Ledogar and Fleming, 2008:26).

These same authors make a link between resilience and social capital. Social capital, as an asset or a resource for resilience, can be a characteristic of the community or the individual. As an individual asset, social capital consists of a person’s relationships to available social resources. As a characteristic of communities, it consists of attributes such as trust, reciprocity, collective action, and participation. Closely related to community social capital is the concept of collective efficacy (Ledogar and Fleming, 2008:25).

As with social capital, resilience can be both an individual and a community (organisational)

characteristic; both individuals and organisations can be said to be resilient.

In the data collected on the Pebbles and Kohatu programmes, notions of social capital and

resilience (both individual and organisational) were mentioned by the individuals who

participated in the programmes as well as those who supported them. Resilience and social

capital are linked to the other themes of value/investment and confidence and aspiration

which have also emerged from the evaluation data.

The notion of the capacity to negotiate life well which builds the social capital of the individual

and the organisation was expressed in a number of ways. Participants mentioned that

meeting those in the organisation “… whose names are on the bottom of things…”, the

“hierarchy” and hearing about their background and their careers, broke down the sense of

“us and them” and gave the participants the belief that they could aspire to positions like that

too. Interestingly, one participant noted that by believing she could aspire to a leadership or

management position, Pebbles helped her to decide to stay in a clinical position and make

that her career – “...you can advance your practice and your career at the coalface. You don’t

actually have to step away…I don’t want to be a manager because, you know, I’m a nurse”

[Pebble 2].

Many participants spoke of Pebbles and Kohatu having the effect of re-igniting their passion

and helping them move from contemplating to doing. The doing involved many things such as

applying for a new position, putting their hand up to lead a project, taking on a different role,

36

enrolling in post-graduate study, embarking on a career path or in one case, applying for a job

elsewhere to “…see how much more there is out there”. Participants also described how

knowledge of the wider environment also enabled them to better cope with clinical practice.

One of the questionnaire respondents wrote “I have found that I have improved resilience to

the pressures nursing practice demands. This through appreciation of the wider picture of the

health environment, for example health costs, health targets, etc.” [RN32].

The CNM perspective mirrored the participants’ views expressed above. They saw in

participants improved communication, a better understanding of the big picture, increased

engagement, and better conflict resolution. As one CNM said of a participant; she had

developed an ability to intervene in difficult situations “…rather than letting things sort of

simmer on the floor”. Other CNMs mentioned improved attitude, the confidence to apply for

other roles and a willingness to support colleagues.

The theme of resilience is best summed up by the following quote from one participant:

… no it hasn’t made me want to be a manager – it has made me want to enhance what I do and do it better and stronger… [Pebble 4]

This is perhaps the essence of resilience as we mean it here. The desire expressed in this

quote has the capacity to build a resilient individual as well as provide social capital to build a

resilient organisation. ‘Big Picture’ According to McCallin, Bamford-Wade and Frankson (2009) nurses throughout the

professional hierarchy often have little idea of health policy and its implications. These

authors suggest that all nurses need to make a... ...conscious effort to develop political awareness and to appreciate the significance of current professional-strategic alliances. Such strategies impact leadership succession planning, not to mention the future of the profession...it is most important that all nurses take a broader view of the nursing profession and its leadership potential that is situated in the wider socio-political world in which it takes place (McCallin, Bamford-Wade and Frankson 2009:43, their emphasis).

These sentiments were also prevalent in the interviews with Pebbles and Kohatu participants

as well as CNMs. Further, this theme was also evident in the questionnaire responses. The

Pebbles and Kohatu participants described how attending the programmes had helped them

to see what many of them referred to as ‘the big picture’:

I think probably the biggest change [for me] was communication with other people...colleagues and other members of staff and managers and managers’ managers! I sort of saw a bigger picture...a better understanding of the hierarchy within the organisation...made them more accessible, made them seem less God-like, which they might not like! Knowing people, knowing people’s roles, who they are, what they do...realising the extent of what goes on in your organisation...The broader picture is really important and that was a realisation, how much more there is out there. [Pebble 4]

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...[meeting members of the nursing hierarchy] has given me a bit more understanding of who does what...sort of actually put people into context. [Pebble 3]

I have a higher level of understanding of how management works, how the hospital works, how the funding and budgeting works, what impact education has upon the entire workforce. [Pebble 2] As somebody who came from [district nursing]...it gave me the beginnings of an understanding of how systems worked, of who the movers and shakers were, what opportunities were possible. [Pebble 5]

[learning about...] different management levels – like who does what and why they do this, and about funding...and how they had health targets...it’s very narrow-minded in the ward and in other areas just concentrating on your own practice and not really thinking about the broader picture...I feel that I may have a little more tolerance for change and may understand some of the pressures that are put upon management...just a little bit more insight. [Pebble 8]

Pebbles and Kohatu participants who completed the questionnaire were given an opportunity

to comment on the programmes. As mentioned above a number of the respondents also

referred to the benefit of gaining knowledge about the wider organisational and health policy

imperatives: ...[the course] has given me a lot of insight to not just focus on where I was working...but to actually look at the larger picture. [RN 18]

The opportunities to meet with leaders within the DHB...was a great way to break down barriers and develop a deeper understanding of why some decisions are made and to take time to look at the bigger picture. [RN 38]

I have a greater understanding of decision-making and change processes and no longer feel so disempowered [RN 11]

Participating in Pebbles enabled me to see outside the small square of where I work. It helped me feel better about the organisation...especially meeting the leaders and managers...I feel much more connected now [RN 14]

The programme opened my eyes to a whole new way of looking at my practice – introducing me to different concepts of team interaction, motivation, how individuals learn, how to value your team’s individuality and acceptance of their uniqueness. [RN 37]

The CNMs also talked about how necessary it was for their RN staff to have knowledge about

a wider perspective than just the ward or unit they worked in.

Learning to see the big picture. I think wherever you are in the organisation it can only be helpful if people are able to see more than just what affects them directly...to be exposed to what is happening in the wider organisation...[CNM1]

I wanted them [RNs] to learn about the wider organisation and not be so insular. I wanted them to think about their job in relation to the bigger picture, such as the perspective of the CEO or the Director of Nursing or the economy and so on. I wanted them to be able to have a broader view of health. [CNM3]

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Value | Investment Michael Cook (2001a:40, our emphasis) argues “Continual investment needs to be made in

the clinical leadership resource as a vehicle to influence and shape both policy and practice”.

This statement has synergy with McCallin, Bamford-Wade and Frankson’s (2009) assertions

outlined above. Further, Cook (20001b) purports that such investment is required throughout

the RN continuum, ie: building leadership capacity at all levels of nursing (and midwifery).

Pebbles and Kohatu participant interviews also reflected these sentiments; they described the

programmes as an investment in both individuals and the organisation. From an individual

perspective, Pebbles and Kohatu were considered to offer participants a chance to reflect on

their practice and career plans. From an organisational perspective, Pebbles and Kohatu

were considered to have the potential to offer the DHB an opportunity to strategically develop

a pool of talented and committed staff who would be well placed to meet future demands in

regard to providing good quality health care:

I would say it [Pebbles] is the breeding ground of, such a cliché, but the future of the DHB or for any people who want to move on...where you can capture peoples’ enthusiasm before it disappears...I think this programme is a good reflection of it’s not about having just a job...it is capturing the future really and giving you the confidence to steer yourself in the future direction. [Pebble 2] [The programmes mean]...bottom line – we want smart nurses. We want good nurses because good nurses provide quality care, they provide quality education for the people coming through; they are good role models. They basically breed a whole new generation of good nurses so if we are going to have a programme that is encouraging people to take the next step to actually act with confidence and with good sound clinical basis for what they are doing, how can you really go wrong – and Pebbles encouraged all of that. [Pebble 3] It gives nurses that are in that senior level that are starting to co-ordinate and starting to get more of an interest in management and leadership, it gives them a bit more confidence, a bit more background information about how that works because the gap between being a senior nurse on the floor and then becoming a manager is huge and there is no in-betweenness to fill that gap....I guess Pebbles gives people a bit more insight.[Pebble 8]

From an organisational point-of-view, CNMs stated that Pebbles and Kohatu sent out a

positive message to the RN staff and midwives that the DHB valued them:

I think [Pebbles] sends a good message to nurses who work in this organisation that the organisation does support their professional development and what I do know of the course, it made sense to me as a programme for developing those nurses who you think are going to maybe take a leadership role. [CNM1]

During the interview process participants were asked “If you had to describe the value of this

programme to the organisation, what would you say?” Reciprocity in terms of positive

attitudes towards the organisation for ‘investing’ in individuals was articulated by participants.

For example, one nurse said:

I would say first of all that it really shows that I was valued because it is a big chunk of time, six whole days over six months...and people feeling valued is so important and so often that doesn’t happen. I guess it is a morale raiser, a confidence booster, it is education in lots of different ways...I think it’s unusual and I think you

39

have to be open to doing different stuff...I think it caused me to think more rather than just do – not just in practice but in everything. I’m not so much of a doer now, I’m a thinker-doer. [When asked for an example, this participant said] ...we have meetings every month for our team and give feedback...now when I give feedback I am firstly more selective about what I feed back and I am also better at planning in advance...I have realised that I can’t do things without planning so now I get to think about them first, plan them, write them down...Also when I communicate with clients, I try much harder now to be creating a partnership earlier on in the relationship with the family. [Pebble 4]

Comments relating to organisational value were also evident in the feedback received via the

questionnaire: It is great to know and have been part of a programme in the Waikato DHB where they value growing and nurturing people in the organisation. [RN 17]

Myself and other colleagues from [unit]...really appreciated being given the opportunity to discuss relevant issue or problems...We simply do not have a forum like this where we can listen to each other and importantly, be heard. We felt so supported and encouraged....[RN 31] It is wonderful that the DHB offers this course and invests in the employees with this programme. [RN 34] [The course] wasn’t just about the job, it was what I could and would contribute to my colleagues, patients and environment. Just what I did for a job was valued. [RN 37]

CNMs talked in terms of the importance of having a programme that had the potential to

refocus and reward nursing and midwifery staff by offering them something tangible with

which to progress their careers.

I’m really pleased there is a programme that can refocus nurses. Not everyone can be a leader or a manager but I think it encourages others because of their enthusiasm...I think this programme can be seen as a gift to staff and it’s good for me to have something nice I can give my staff. [CNM3] ...perhaps even the thought that I would recommend her for [Pebbles] may have had an influence on her development. [CNM1]

CNMs also considered Pebbles and Kohatu to be intrinsic to retention and succession

planning strategies:

...for the unit it’s been good because we’ve got someone that we can nurture and hopefully she will stay....I think that this programme will hopefully, you know, provide a structure and a pathway to guide staff who have the potential into these leadership roles so that you have someone who would have those skills to take on – whatever – whether it is a clinical nurse manager role or some other role but in leadership position within the hospital. [CNM2] ...I guess it is sort of about succession planning...not just for [your unit] but also the other senior nurses that might want to move through or somewhere else in the organisation...you are developing [staff] for the organisation rather than just you. [CNM5] ...you mention what is the value for the organisation [in having Pebbles and Kohatu] and I really do think it is being able to grow leaders, really organically...it encourages the building of leaders across the organisation. [CNM4]

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Participants also talked about how they considered the process of being nominated for the

Pebbles and Kohatu programmes was indicative of the value their CNMs saw in them:

Because what they [CNM} are saying, they think you are really good for this and gave me a little list of all the compliments that have been given, and it was really flattering. [Pebble 3]

...I felt a bit special which was really nice and unusual because that doesn’t often happen. [Pebble 4]

...it was nice for someone to be interested in you and interested in your career and try and nurture you towards your goals. [Kohatu 1]

It just made you feel valuable...you were given that time to think about new development and to know there were resources out there that would welcome you when you were ready to move through your career. [Pebble 6]

In general the majority of comments regarding Pebbles and Kohatu were overwhelmingly

positive. However, one participant said that she felt Pebbles had been of little value to her

because,

...I think I am too old, too far down the track...I’ve worked in this hospital for a long time and I don’t think it was appropriate really. [Pebble 7]

Other participants also spoke of the need for participants to embrace the opportunity they

were given as well, saying

It [the programme] can be as valuable as the Pebbles participant wants it to be. It has huge potential but in the end it comes back to what each person wants to invest. [Pebble 1]

Three sub-themes revealed in both the questionnaire and interview data are also worth

comment.

Mentorship As indicated above, participants and respondents did not consider that the programmes had

given them the opportunity to develop mentoring relationships. While several participants said

there were feelings of collegiality engendered amongst specific Pebble and Kohatu groups

while the six months programme was running, with the exception of one area, very little in the

way of mentoring support was either offered or provided once participants returned to their

clinical wards/units. Mentoring is considered a key component in leadership development

programmes (Bretschneider, Eckhardt, Glenn-West, Green-Smolenski et al 2010; Dyess and

Sherman 2011; Kleinman 2003; Meehan and Green 2002; Redman 2006). In light of this, any

future leadership course would require ‘investment’ from the WDHB in relation to the

preparation and establishment of a mentoring programme. These can be set up as internal

learning and development programmes or via external organisations, such as tertiary

institutions or professional bodies. The literature is not explicit as to whether formal or

informal programmes, or a combination of both, are most beneficial (Davidson, Elliott and

Daly 2006; Kleinman 2003; Meehan and Green 2002; O’Neil, Morjikian, Cherner and

Hirschkorn et al 2008, Redman 2006).

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Course Content In the main, the majority of interview participants and questionnaire respondents found the

content of Pebbles and Kohatu relevant. They also stated that the programmes provided

them with opportunities to reflect upon their clinical practice. However, it was noted that one

aspect commented upon was the need for further in-depth training on the topic of conflict

resolution in relation to both patient/patient families and nursing colleagues. Some Pebbles

and Kohatu also stated that there were “too many topics” or the topics canvassed were not

applicable to their clinical areas.

Literature reveals a wide and varied number of nursing leadership programmes, for example

High Performance Development Models and Champions Programmes (Goudreau and Hardy

2006); Clinical Leadership Development Project (de Casterle, Willemse, Verschueren and

Milisen 2008); and the Health Leadership Alliance and American Organization of Nurse

Executives competencies (Jones 2010). Not only are the topics covered in nursing leadership

courses diverse, but so are their theoretical underpinnings which range from authentic,

congruent, resonant, connective, renaissance, transactional and transformational (Cook

2001a; Cummings 2006; de Casterle, Willemse, Verschueren and Milisen 2008; Huston

2008; Shirey 2006; Stanley 2008) to shared governance models (Bretschneider, Eckhardt,

Glenn-West, Green-Smolenski et al 2010). While it is not within the scope of this study to

comment specifically on the content of Pebbles and Kohatu, it is noted that topic need to be

congruent with the aims and objectives of the programmes. The aims and objectives also

need to reflect the wider organisational perspective and direction.

Pebbles Nomenclature Participants were asked about the name ‘Pebbles’. A number were in favour of retaining the

name and spoke about the metaphor of the ripple of a pebble in a pool spreading influence.

However other participants stated that a more ‘grown up’ or professional name was

warranted.

6. Study limitations Limitations to this research should be acknowledged. Data was collected from a relatively

small sample of potential participants and therefore it was not possible to generalise the

findings to all nurses and midwives or the charge nurses/midwives who have participated or

nominated people for Pebbles and Kohatu. Despite assuring participants that interview

information would be de-identified it is possible that views expressed were guarded in order to

protect against any potential negative reaction. The views of the Nurse Co-ordinators Practice

Development also had capacity to contain favourable bias because of their intimate

involvement in the setting up and continued facilitation of the programmes. In order to mitigate

42

this very little data from that focus group has been utilised. However, useful background

information from the interview has been incorporated into this report.

This study did not expressly look to ascertain similarities or differences between the Pebbles

and Kohatu programmes. While acknowledging there were important differences in the way

these programmes were run due to the cultural underpinnings of Kohatu, further investigation

is required in order to develop an in-depth understanding of participants views about these

factors.

This study was not able to show a clear linkage between leadership training and improved

patient outcomes. The same can be said for leadership training and its positive influence on

the nursing team. Although anecdotal evidence appears to support these contentions, further

research is required in order to ascertain whether this is the case.

7. DISCUSSION

Findings from this research indicated that nurses, midwives and the charge nurse/midwife

managers who participated in this study strongly supported and endorsed the Pebbles and

Kohatu programmes. As the analysis revealed, participants considered the programmes as a

form of investment that ‘added value’ to individual nurses, their clinical wards and units and

the wider District Health Board. This investment, as Cook (2001b) suggests, is most effective

when aimed at all levels of the health care team but is especially relevant to nurses and

midwives providing ‘front-line’ patient care. The ‘pay-off’ from this investment should see

nurses and midwives better able to contribute to the formulation of nursing and midwifery

practice, strategic planning and health policy development (Cook 2001a; McCallin, Bamford-

Wade and Frankson 2009). As indicated in this report, a positive from an organisational

perspective is that staff who are presented with learning and development opportunities, such

as leadership training and post-graduate study opportunities, are more likely to be engaged,

resilient, confident and committed employees which in turn improves patient care and

outcomes. As reported above, the programmes have proved to be a catalyst for a number of

participants in relation to their seeking post-graduate qualifications, engaging in PDRP and

applying for senior nursing roles. Many also took the opportunity to reflect on their current

career status, with some making changes if required. An increased use of evidence-based

practice was also reported by a number of nurses.

This study also mirrored findings in the literature relating to the importance of nurses and

midwives possessing not only knowledge and skills relating to their clinical microcosm but

also the need to be cognisant of what is occurring within the wider social environment. This

‘big picture’ trope is well documented throughout nursing literature (Cook 2001a, Morgan

2005, Redman 2006, Stanley 2008) and was evidenced in the interviews held with Charge

Nurse/Midwife Managers and Pebbles and Kohatu participants, as well as from respondents

43

who completed the questionnaire. The ‘big picture’, according to Sorensen and Hall (2011), is

a phrase which is not just about ‘knowledge’ – whether it be practical nursing or theoretical

knowledge - but involves an in-depth understanding of the social, political, economic and

managerial worlds and includes an appreciation of how these impact on the mechanisms of

health care delivery to the general population as well as within discreet clinical settings. An

example of this can be seen in the way health care has become increasingly subjected to

managerial ideologies requiring nurses and midwives to be financially literate; in other words,

they need to posses a clear understanding of budgets and the implications of these on

decision-making processes and the acquisition of resources (Sherman and Pross 2010). The

results of this research indicate that participants in general now possess a deeper

understanding and appreciation of the wider health environment and the role of management

at both organisational and nursing levels. Notwithstanding this, the ‘big picture’ perspective

also includes political savvy. As Huston (2008) suggests, politics is ubiquitous and therefore it

is essential that nursing and midwifery leaders have a clear understanding of the politics at

play within their organisations. This finds them better placed to intervene or advocate for

patients and nursing and midwifery professional issues. However, our study did not reveal

whether participants have chosen to become more ‘politically active’.

While the findings as reported could be seen as an endorsement of the programmes, in light

of the literature reviewed some factors require further consideration. It is evident from the

study that the aims and objectives of Pebbles and Kohatu have lacked clear direction. As one

of the facilitators of the programmes stated:

Questions for the organisation…what is the need we are trying to fill and what do we fundamentally want to achieve and what is the best method that we know of to produce those outcomes? [NCPD]

Complexity theory challenges management to consider organisations as a ‘whole system’ as

opposed to discreet parts or segments that rely on an inward-looking focus, such as

concentrating on specific budgets or performance targets (Plsek and Wilson 2001). These

authors argue that “complexity based organisational thinking suggests that goals and

resources are established with a view towards the whole system, rather than artificially

allocating them to parts of the system (Plsek and Wilson 2001:746). In addition, Plsek and

Wilson contend, it is the relationship between the parts that is more important than the parts

themselves. If we consider these concepts in relation to the Pebbles and Kohatu programmes

it is evident there is a disconnect between the parts and the whole system as well as the inter-

relationship between these. For example, the programmes are currently not part of the

organisation’s strategic direction, especially in relation to succession planning. The

programmes also lack clearly stated aims and objectives and learning expectations and

outcomes have not been articulated. Importantly, ‘leadership’ has not been defined and

therefore there is potential to confuse and conflate the terms leadership and management.

44

Another important aspect of complexity theory relates to development of a ‘feedback loop’.

Fraser and Greenhalgh state health care education needs to focus on staff developing

capability as opposed to competence. While recognising both are important, staff who

possess capability are more likely to “adapt to change, generate new knowledge, and

continue to improve their performance” whereas competence pertains to individuals who

“know or are able to do in terms of knowledge, skills, attitude” (Fraser and Greenhalgh

2001:799). Educating health practitioners to appreciate and understand the complexities of

the health care environment in order to be “creative decision makers” as opposed to

“checklist” operators is more likely to benefit patients and practitioners (Fraser and

Greenhalgh 2001; Schick 1996). One way to assist is through the provision of a feedback

loop which requires practitioners to detail their learning needs, discuss how to enact these,

take action, and then report on any outcomes related to those actions (Fraser and

Greenhalgh 2001). Data from this study showed that to some extent, Pebbles and Kohatu

enabled participants with opportunities to reflect on practice. However, provision of a more

formal feedback loop through a facilitated educational process would appear to have the

potential to benefit health practitioners and improve the overall standard of patient care.

Leadership to enact the above would be required.

All of the aspects above require addressing because workforce planning is being increasingly

profiled as requiring urgent attention and, as mentioned above, was clearly evidenced

following the HWNZ clinical leadership forum held in June 2010. To this end a New Zealand

Centre of Excellence in Health Care Leadership has been established. This centre is hosted

by the University of Auckland and will be linked to the Faculty of Medicine and Health Science

and the Faculty of Business and Economics as well as the University’s Leadership Institute.

One of the stated aims is to “improve[e] leadership at all levels across the health sector and

provid[e] a resource for all professional groups and managers”15. Part of this work will include

the need to adopt leadership succession strategies because

Leadership succession planning is an essential business strategy that stands to benefit healthcare organizations in general and nursing in particular. Preparing a deep pool of future nursing leaders for healthcare will contribute both to the successful performance of healthcare organizations and to the quality of patient care services they deliver (Redman 2006:296).

A succession plan, according to Redman (2006:292) involves “a long-term business strategy

that requires both strategic thinking and action” in order that organisations anticipate

leadership needs and ensure education is provided to meet the competencies required. Of

course, Fraser and Greenhalgh (2001) would argue that enhancing the capability capacity of

staff is of equal importance. A succession plan (McCallin, Bamford-Wade and Frankson

2009:42, Redman 2006) therefore requires:

1. Development of an organisation-wide strategy in terms of specific roles and skills

15 http://www.healthworkforce.govt.nz/our-work/clinical-leadership (retrieved 15/06/11)

45

2. Personalised development plans for targeted individuals/groups (incorporating

clarification of “leadership competencies, skills, strengths and learning needs,

together a goal-directed proposal for action and development.”)

Redman (2006) also argues that the process of designing and implementing a succession

plan should promote discussion about the values and competencies required to underpin an

organisation and this in turn should enable a better ‘fit’ of potential candidates to leadership

positions. This requires organisations to undertake “an assessment of specific positions...and

the desirable skills and qualities for individuals to fill [those...as well as] a systematic

assessment of individuals...in terms of their leadership capabilities or potential for moving into

leadership positions if developed and supported over time (Redman 2006:293). McCallin,

Bamford-Wade and Frankson (2009) point to how a succession plan should involve nurses

being actively involved in “replacement identification”. This requires assessment of future

needs and potential ‘replacements’. Mentoring becomes an important component of

replacement strategy as nurses/midwives are given opportunities to develop skills and

become involved in projects while under the guidance and tuition of senior colleagues as well

as other appropriate educational opportunities. This strategy has been linked to improved

recruitment and retention rates (McCallin, Bamford-Wade and Frankson 2009).

Returning to a complexity theory viewpoint, the form and function of nursing leadership

requires a holistic perspective. In other words – it has to be considered through a myriad of

lenses – competing lenses at times – patients, patients’ families, nurses, medical staff, allied

health, secretarial and support staff, wider society and so on. This environment is ever-

changing, therefore flexibility is required in relation to succession plans as well as the

programmes utilised to prepare staff for future leadership roles.

7. CONCLUSION

This study evaluated the impact of Pebbles and Kohatu on the nurses and midwives who had

attended these programmes. The methodologies utilised provided evidence which suggested

that overall the participants who took part in this study benefitted in a number of ways and

these are outlined above. Participants also pointed to some changes they considered would

improve the programmes; again these are described in the body of the report. From the

perspective of the Professional Development Unit, evidence from this study suggests that

developing leadership skills at the clinical interface is important to ensure that, in the future,

the Waikato District Health Board will have nursing and midwifery staff who possess the

necessary skills to deliver optimal patient care in a way which is supportive of patients and

health care professionals. This will require, as Jasper and Jumaa (2005) state, an

environment where leadership is both able to and encouraged to influence what happens

tomorrow today.

46

RECOMMENDATIONS Recommendations resulting from this evaluation are:

The Pebbles and Kohatu programmes received a generally positive endorsement from

research participants and respondents. In order to retain and build on gains made to date the

following recommendations are made:

1. The literature alludes to levels of confusion concerning the terms nursing/midwifery

‘leadership’ and ‘management’. It is recommended that the Waikato District Health

Board’s Professional Development Unit be tasked with defining ‘clinical

nursing/midwifery leadership’ as it pertains to the wider organisation in order to

identify potential leadership training requirements.

2. Evidence from the literature points to the necessity for health care organisations to

develop leadership succession plans in order to address patient care and safety

issues as well as the nursing/midwifery work environment. It is recommended that the

Professional Development Unit, in consultation with the Nursing Directorate, be

tasked with researching and drafting a nursing/midwifery leadership succession plan

which is strategically aligned to overall Waikato District Health Board and Health

Workforce New Zealand goals.

3. The literature clearly outlines the need for organisational direction and support in

regard to clinical nursing/midwifery leadership programmes. Data from this study

indicated low-level direction and support for the programmes. It is recommended that

the Professional Development Unit, along with support from the Nursing Directorate,

undertakes a needs-based assessment in relation to both a leadership succession

plan and, pertaining to this, clinical nursing/midwifery leadership requirements within

the District Health Board.

4. If the Nursing Directorate directs the Professional Development Unit to continue

implementation and facilitation of a clinical nursing/midwifery leadership programme it

is recommended that programmes establish clear aims and learning objectives. It is

further recommended that these aims and objectives be outlined in writing and

circulated to all course participants and their CNMs prior to the commencement of

any programme. The implementation of a feedback loop should also be an integral

part of any learning outcomes.

5. In order to best meet the staff development requirements it is recommended that

further investigation is required into the compilation and eligibility of any clinical

leadership programme. For example, a programme for nurses/midwives who have

47

been in practice 10 years and less, another programme for nurses/midwives who

have been in practice more than 10 years.

6. Evidence points to the availability of a variety of leadership models (such as

authentic, transformational or transactional). It is recommended that, in consultation

with the Nursing Directorate and Professional Development Unit, agreement is

reached as to the preferred model(s) a leadership training programme is based upon.

It is further recommended that the content of any programme reflect that particular

model(s).

7. The literature details the need for mentorship when building leadership capacity

within clinical areas. Although Pebbles and Kohatu had been considered to offer a

form of mentorship to participants, this was not borne out by the research. It is

recommended that all future programmes require clinical wards/units to provide

formal mentorship for each leadership participants. In this event, mentorship training

would be required of potential mentors.

8. While data indicated reasonable support for the nomenclature Pebbles to continue, it

is recommended that further discussion is required in order to decide whether a name

clearly identifying the programme as a nursing/midwifery clinical leadership

programme be used instead.

9. Following comment from Te Puna Oranga in regard to the name Kohatu, it is

recommended that further consultation be undertaken on this matter.

48

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Appendix II

The BEET Building Effective

Engagement Techniques

A guide to bringing people together co-operatively to find

sustainable solutions

Lawless, J and Walsh, K (revised, 2008)

2

The BEET

Building Effective Engagement Techniques

A guide to bringing people together co-operatively to find sustainable solutions

Lawless, J and Walsh, K (2008)

Introduction

In our work lives, we are often seeking solutions to deal with ideas,

problems and issues. Even the best solutions cannot work if the people

involved do not support them. So when questions of clinical change

arise within or between clinical units, it is essential that a robust co-

operative process of engagement take place so that our agreed

solutions will be supported and sustained. Life would certainly be

simpler if, when problems needed solving or solutions needed

implementing, everyone would get in behind our good ideas. In

reality though, generally everyone who has a stake in the decision or

outcome reserves the right to be part of the process, and it is this

complex dynamic interaction of people, issues, ideas, constraints etc,

that so often sees us come to grief during change processes. So how

can we do it differently – and better? One approach that we have

found to be very effective lies in preparing the ground carefully before

any attempt is made to engage around anything that requires co-

operative interaction between two or more parties. This resource guide

uses a series of simple reflective exercises to step you through the

process of setting the scene for co-operative engagement. It is not

about finding solutions; if the process of engagement is constructive,

solutions will emerge.

3

While the process may take two or more hours to complete, this

investment should be amply repaid when the engagement process

gets underway. Much of the time (and frustration) that is experienced

stems from not taking the time to set the scene well.

The BEET guide steps you through clarifying the question behind your

issue, idea or problem, establishing your reasons for seeking

engagement and change, evaluating your evidence, identifying who

else you need to engage with and describes a process by which

stakeholders can meaningfully engage as partners.

The BEET is divided into four sections:

1. Puzzles and Purpose – identifying the question to be answered

and the reasons behind the engagement

2. Evidence – assessing the strength of the proposal for

engagement

3. Context – considering the environment and people within which

engagement will occur and identifying who else needs to be

involved

4. Facilitation – how to bring people together constructively.

Each section consists of straightforward exercises related to each

broad content area that are designed to tease out the key messages.

Each exercise is important and it is advisable not to skip ahead. The

guide incorporates built in checkpoints. These checkpoints review your

progress towards effective engagement and are used in the final

exercise to prepare your statement of engagement in preparation to

taking it out to prospective partners. When you have completed the

process you will;

• have developed clarity around the purpose of your proposed

engagement;

4

• have identified the key stakeholders;

• be clear about any remedial relationship work that is required;

• have articulated a simple positively framed question to take out

to your prospective engagement partners and

• have some ideas about how to make the first stage of

engagement get off to a great start.

Puzzle and Purpose

You have probably begun with an idea, issue or problem and possibly

you already believe that you know what the solution should be. You

may have also realised that if you try to impose your solution on

others who have an interest in the process and outcome, the odds are

that you will meet with resistance. Solutions don’t solve problems,

people do. If you want to take others with you, it is necessary to take

a step back, put aside your own ideas for now and identify what

brought you to this point. This section is designed to help you clarify

your thinking and assists you to identify the heart of the matter

around which you wish to engage. We prefer to use the term ‘puzzle’

rather than words such as ‘issue’ or ‘problem’ as these can imply fault

or confrontation and may mobilise resistance before you even begin.

The concept of ‘puzzling’ suggests a more co-operative effort. Puzzles

have a different focus to problems and require people to think in a

different, creative and more positive way. Puzzles are shared. Seeing

problems as puzzles uses our imagination to reframe something old

into something new. We seldom ask ‘whose puzzle is it anyway?’ We

seldom say ‘that’s your puzzle’ and of course we are unlikely to say

‘who caused the puzzle in the first place?’ Puzzles are often solved with

the help of others and once you have solved one puzzle other puzzles

5

will often be easier to solve. The way we articulate puzzles is as

‘positive unconditional generative questions’. ‘Positive’ in the sense

that the language you use is not negative or critical of other parties,

‘unconditional’ requires that there are no preconditions or solutions put

forward at the beginning, ‘generative’ means that the puzzle requires

more than a yes/no response, and ‘question’ refers to the way we

frame the puzzle as a question to be answered.

Finding the puzzle behind the proposal

Exercise 1: Naming your idea, issue or problem

So you want to engage someone about something. What’s it about?

…………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………

Now look at this statement again and think about how you could turn

it from a problem, issue or idea into a question (or puzzle) that can be

explored by interested parties. Remember, the way you word things

can make a great difference to how your proposal will be received.

(See appendix A for an example).

Exercise 2: Identifying the puzzle question

a) Rewrite your statement from Exercise 1. Begin with “how can

we….”

…………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………

b) Now put your puzzle question to the PUGQ test (positive,

unconditional, generative, question. This is to make sure you

are not being negative or critical of other parties, that there are

6

no preconditions or solutions put forward at the beginning, and

the puzzle or question requires more than a yes/no response.

1. Positive: Is your puzzle framed in a way that does not imply any criticism? 2. Unconditional: is your puzzle free from pre-conditions or solutions? 3. Generative: Is your puzzle open to a range of possible solutions? 4. Question: Does your puzzle require more than a yes/no response?

If you answered yes to these questions then it is likely that this is a

puzzle that will be well received by others.

Let’s go on to identify the purpose of engaging around this puzzle –

what you are hoping to achieve. (Remember to be careful not to

prescribe a particular solution as the outcome)

Exercise 3: Identifying your purpose

If you were successful in finding a solution to the puzzle, what would

be different and/or better for patients and service providers?

3a) our patients would see/be….. ………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………… 3b) our staff would see/be…. …………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………

7

3c) our service would be…… …………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………

These statements, 3a, 3b and 3c define your purpose – the reason you

want to engage in a change process.

The final important test of a successful puzzle is to relate it to the core

purpose of your profession and/or service – to the heart of your

practice (HoTP). This exercise provides you with a touchstone for the

puzzle and is helpful when seeking to engage with others.

3d) How does the puzzle relate to the heart of your practice? ………………………………………………………………………………………………………. ………………………………………………………………………………………………………. ……………………………………………………………………………………………………….

Congratulations! You have now established your puzzle and your

purpose. Transcribe your statements from Exercises 2 and 3a-d into

the box below. (Add linking words if necessary so that the new

statement makes sense).

Checkpoint 1: We are proposing to engage with our key partners around the question of… with the purpose of….. This puzzle relates to the heart of our practice/work in the following way……..

8

Evidence

When you take out your proposal to others, even though it is positively

framed, don’t expect others to join in without expressing some doubts

or scepticism. They may not have seen it from their end quite the way

that you have. It may also be new to their thinking. It is important to

take the time to look for any evidence you already have that supports

your view that this is something worth spending time on. This

evidence will help confirm that the issue you wish to engage about is

in fact an issue and it will help when presenting your proposal to

others.

The two types of evidence most likely to be helpful are firstly anything

that you can establish from your current experience that suggests that

change would be beneficial and secondly evidence from elsewhere that

supports your findings. This may include audit data, evidence from the

literature or best practice guidelines, expert opinion, incidence data,

etc.

At the end of this section you will have established the foundation of

evidence that supports your proposed puzzle and purpose. Remember

you are not looking for solutions at this stage.

Exercise 5: What do you know about the reasons for proposing

change? (this can be anecdotal evidence/information as well as

more formal measures)

5a. What has been happening that has suggested to you that

change might be indicated?

9

………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………… 5b. What evidence are you already aware of (if any) that

supports your view that change might be indicated, (e.g. other

services experiences, benchmarking audits, best practice

guidelines, literature etc)

…………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………

Exercises 5a and 5b summarise the evidence that supports your

proposed engagement. Transcribe these statements into the

Checkpoint 2 box.

Now that you are clear about your puzzle, purpose, and evidence

we can move on to looking at preparing the way for taking your

proposal out to others

Checkpoint 2: Supporting evidence/information The evidence on which we are basing our proposal is…

10

Context Considering the environment and identifying who else needs to be

involved

One common mistake that is made that stops co-operative

engagement in its tracks is to jump in enthusiastically without giving

consideration to how others are likely to react and also to the

characteristics of the setting which may help or hinder your progress

towards effecting sustainable change. The exercises in this section

encourage you to reflect on both the people and the environment, with

a view to identifying who needs to be involved, who needs to be

informed and any factors that are present that need to be dealt with

before engagement takes place.

Exercise 6: The People - identifying parties with an interest in

your proposed engagement

6a) Make a list of everyone who you think may have an interest

in knowing about or being involved in your proposed

engagement process. This may be services or individuals within

services (including your own) or clients. It is important that you

cast your net wide as these are the individuals or services that

are most likely to contribute to the success of, or be affected by,

the potential outcomes. These people are potentially both your

biggest allies and your biggest critics

List ……………………………………. ……………………………………… ……………………………………. ……………………………………… ……………………………………. ………………………………………

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……………………………………. ……………………………………… ……………………………………. ……………………………………… ……………………………………. ……………………………………… ……………………………………. ……………………………………… ……………………………………. ……………………………………… ……………………………………. ……………………………………… 6b) Referring to the list of interested people and parties that you

identified above:

• identify the key partners you will need to work with directly as

part of the engagement process

…………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………

• identify who you will need to engage in consultation during the

process

…………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………

• identify those you need to keep informed and with whom you

will need to establish communications

…………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………

• check that you have included everyone listed earlier. If anyone

has dropped off your list give reasons why

………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………..

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6c) which (if any) of these people/parties have you had previous

positive engagement processes with? Which (if any) have you

had unsuccessful experiences with?

Positive experience Negative experience ………………………………………. …………………………………………….. ………………………………………. …………………………………………….. ………………………………………. …………………………………………….. ………………………………………. …………………………………………….. 6d) what do you think will be the initial “gut” response to the

proposal amongst the people/parties you have identified? Is this

already a “hot” issue amongst some of the parties?

……………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………… 6e) is it your impression that the parties will be approaching the

engagement with an intention to succeed? Do you think there

will be any preconditions to engaging with you? (e.g. this won’t

be supported if it involves extra resources or increased

workload).

………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………… 6f) consider your own attitude. Do you already have a solution in

mind? If yes, how attached do you feel to this particular

solution? Remember that you are committed to finding a solution

to the puzzle, not your particular solution. Working together

opens the possibility that even better solutions may emerge.

……………………………………………………………………………………………………………………………………………………………………………………………………………………

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……………………………………………………………………………………………………………………………………………………………………………………………………………………

Given your responses in this section, write in Checkpoint 3 your

reflection on what you see as the main positive and negative points

about the potential key partners that you have identified and your

relationship with them.

You’ve now thought about the people you will be engaging with. The

next exercise looks at the environment in which engagement around

change will take place

Exercise 7: Understanding the readiness of the environment

This series of questions helps you identify the current capacity and

resource available that may affect your proposed engagement.

Checkpoint 3: Our key partners are likely to be…… Our key supporters are likely to be… We have a good relationship with We have some work to do on our relationship with… The overall response to our proposal is likely to be…

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7a) How much time and energy can you/your service devote to

the process? Thinking about the timing of this proposal, what

else is going on in the environment at this time?

………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………… 7b) Do the staff and people in the services that this will involve

have the emotional and cultural capacity to cope with this

change at this time?

………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………… Exercise 8: Identifying structural enablers and disablers Your puzzle can be enabled or frustrated, depending on your

organisation’s strategy, policies and systems support and also .

Giving thought to this prior to engaging can be useful to getting

your activity underway

8a) Is there any existing strategy, policies, procedures or

systems that could enable your puzzle?

……………………………………………………………………………………………………………………………………………………………………………………………… ………………………………………………………………………………………………

8b) Is there any existing strategy, policies, procedures or

systems that may frustrate your puzzle?

……………………………………………………………………………………………… ……………………………………………………………………………………………… ………………………………………………………………………………………………

15

Read through your responses for exercises 7 and 8. What does this tell

you about the context and environment at this time, particularly the

ability to cope with a change process? Write your reflections into

Checkpoint 4.

If your analysis showed you that the environment and people are not

well placed to cope with this proposal at this time, we are not

suggesting that you don’t take it forward but you may need to identify

what needs to happen before you introduce the proposal

Checkpoint 4: the context and the environment My analysis of the readiness of the environment is………..

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Facilitating Engagement You now have all the information that you need to decide what steps

should be taken in preparation for taking your proposal out. You know

what you want to do, why you want to do it and who you need to do it

with. This section aims to assist you to go to your identified partners

and engage with them in a way that is more likely to mobilise their co-

operation as partners

Exercise 8: Summary of information

Thinking about what you have learned about the people, the

relationships and the environment, what do you see as the main things

that may get in the way of:

a) a successful engagement

………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………

b) a successful process ………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………

c) a successful outcome ………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………

What do you see as the things that may support:

d) a successful engagement ……………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………

e) a successful process

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………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………

f) a successful outcome ………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………

It is very likely that you have identified some actions that it would be

wise to undertake before you can begin engaging around your

proposal. This is when relationship building or rebuilding needs to

happen. A climate of trust for this particular engagement needs to be

fostered by acknowledging past difficulties and past and present

strengths between the parties. Now is the opportunity to clear the air

and show how this engagement process will be different.

Exercise 9: Establishing your pre-engagement action plan

This exercise assists you to reflect on your ability to take the proposal

forward and to identify action points to increase the chances of

success.

9a) Given what you now know, consider whether you think that

you have the skills to take the proposal forward and if it would

be useful to seek advice/support – if yes, from whom? What

have you learned about the way you will need to facilitate the

engagement process?

…………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………

9b) What specific actions have you identified (relating to the

people who will be involved) that you need to act upon prior to

taking your proposal out? Are there people/services identified

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where it would be beneficial to undertake some relationship

building/rebuilding before launching your proposal? If yes, what

action could you take to achieve this?

…………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………

9c) What specific actions have you identified relating to the

environment and resources that you need to address prior to

taking your proposal out?

…………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………

Checkpoint 5: List of specific pre-engagement actions To prepare myself/ourselves I/we will….. To prepare the environment I/we will…… To prepare the people who will be involved I/we will……

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Exercise 10: Taking your proposal out to your key partners

10a) You are now ready to take your proposal out for others to

consider. What is the message you wish to take to your key partners?

This should be a message of engagement and working collaboratively.

It must not prescribe a solution. Draw from your statements in

Checkpoints 1-3 for this exercise

“We would like to discuss with you how we may work together

around a proposal to ……………………..

with a view to achieving……………………………………

The reason for undertaking this proposal is.........

and we hope that working together we may be able to generate

a solution which is beneficial to us all and the clients for whom

we care.”

10b) Your next action is to communicate this message to everybody

that you identified as having an interest or stake in this proposal. Ask

them to state what level of involvement in the process they would

wish. This will range from active involvement to being consulted at

key points, providing advice or simply being kept informed.

10c) Once you have the responses, seek to get agreement in principle

from the key partners on engaging around the purpose of the

proposal. Be prepared to modify your proposal to get ‘buy in’ but

beware of ‘dumbing down’ the purpose simply to gain consensus. Just

as we asked you to put aside any preconceived solutions, you may find

that your potential partners try to put preconditions around the

engagement and this needs to be managed. Appendix B contains ideas

for managing this situation. Set a meeting to agree on the terms of

the engagement and the process that will be used. Be clear that you

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believe that in this way of working the solutions will evolve from the

process of engagement and that you are not making any particular

demands of them or their service. Acknowledge that the process is

now no longer your process but a shared process in which all the

parties have equal ownership.

Where to from here?

By using the BEET tool you have now set the scene for a process of co-

operative engagement. You are taking out a proposal that has a clear

purpose, and evidence base and which invites participation in an open

and solutions-focused way. Using this approach should significantly

enhance your chances of success. We suggest that in order to get the

best outcome from the process of engagement you work with your

partners using similar principles and a systematic solutions-focused

process of action change such as Practice Development to generate,

implement, evaluate and refine your practice change.

Good luck!

Copyright: Jane Lawless, Practice Development Facilitator, Waikato District Health Board, Hamilton, New Zealand. Ken Walsh, Clinical Professor of Nursing, Graduate School of Nursing and Midwifery, Victoria University of Wellington and Waikato District Health Board, New Zealand. The BEET Tool may be freely copied and used with the proviso that acknowledgement will be given to the authors and we would request feedback on the tool so that we can further evaluate its effectiveness in practice. Feedback can be sent to lawlessj@waikatodhb.govt.nz

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Appendix A:

Example of framing a positive, unconditional, generative question

What do you want to engage around? Currently central lines are inserted in radiology. Currently we know that we can have delays of up to five days waiting for a slot in radiology. Treatment is delayed. We want to engage with radiology to discuss changing the process so that central lines can be inserted in the ward Identifying the puzzle question Rewrite your previous statement beginning, “how can we…. and making sure that you are not being negative or critical of other parties, there are no preconditions or solutions put forward, the puzzle requires more than a yes/no response, and there is a question to be answered How can we get radiology to agree to change the process so that central lines can be inserted in the ward and stop the unacceptable delays? Is your question framed positively? Well, it is a bit marginal because it suggests that we think radiology is doing a bad job Is there anything about your position at this point that has preconditions or solutions attached to it? Yes, we are proposing that it would be better to do the central line procedure in the ward Does the question require more than a yes/no answer? Yes So if you were to take the implied criticism out and take the suggested solution out, what could your question be? How can we improve our service so that patients requiring PICC lines get them safely inserted within 24 hours so that there are no significant delays to treatment? Is your question now Positive, Unconditional and Generative? It is stated positively, it has no preconditions or predetermined solutions in it and it is framed in a way that should generate a response from the partners who engage around finding a solution to this question – so yes

22

Appendix B Declaration of interests, agendas, preconditions, positions and predetermined solutions Dealing with preconditions, positions and predetermined solutions. When the parties engage around a question it is normal for them to have preconditions positions and predetermined solutions during the pre-engagement negotiations or when they first come to the table. You may also have some. If these remain as hidden agendas they can seriously get in the way of an open and generative process. We need to allow everyone an opportunity to declare preconditions, positions and predetermined solutions in a way that does not stifle the process. Example of a precondition: “I can’t agree to anything if it has a monetary requirement attached to it” This immediately narrows down the range of possible solutions that will be considered Example of a position: “I think that PICC lines should continue to be inserted in radiology” Positioning has the effect on the process of putting the parties in attack and defend positions. Once a stake has been put in the ground it becomes very difficult to move the position and the focus on finding a mutually agreeable solution to the puzzle can get lost. Example of a predetermined solution: “I believe that the answer to this question will be that PICC lines should be inserted in the ward” This risks other parties feeling that they also need to take positions and defend them and also shuts down generative, creative dialogue aimed at finding the best possible solution Example of a qualified position: “while my current position is that PICC lines should continue to be inserted in radiology, I am open to other options and I accept that we may find another acceptable solution” While it is obviously preferable to avoid preconditions, positions and predetermined solutions altogether in reality they will be there and it is better to have the parties declare them than to hold them as hidden agendas. When agendas remain hidden, that person does not participate whole-heartedly in the engagement process as they are secretly holding on to their particular precondition, position or solution and may seek to sabotage other ideas if they do not seem to fit with their own. It is useful to give everyone an early opportunity to declare any preconditions, positions or predetermined solutions but to encourage them to do it in way that leaves the door open for them to change tack during the process. The way we do this is by asking them to declare their attachment to a precondition, position or solution, rather than an absolute immovable position. If they are given an early opportunity to declare their attachment it can be openly on the table and they then feel freed up to participate in exploring a wider dialogue with the other partners to the engagement and there is no loss of face if they later wish to become unattached to the position that they started with. Here are some examples of how to do this:

23

Example of declaring attachment to a position: “I need to state that at this early stage of the process I do hold the view that radiology is still the right place for PICC lines to be inserted, however I agree that the delays are not acceptable and I am committed to exploring all possible solutions” Example of declaring attachment to a precondition in a generative way: “I am finding it difficult right now to see how I could commit to a solution that required monetary expenditure but I am open to exploring all options and I am committed to finding a solution to the question” Example of declaring a predetermined solution in a generative way: “One idea that I have already had that I would like to put in the mix is the possibility of inserting the PICC lines in the ward. However I am open to exploring all possible solutions and I am committed to finding a solution to the question” This style is not one that most of us are used to but it is worthwhile to persist as this can be the difference between the process continuing to a successful conclusion or breaking down. Acknowledgment We wish to acknowledge the work of Kitson, et al, (1998) which helped inspire us to develop the BEET around the key areas of evidence, context and facilitation.

References: Kitson, A., Harvey, G. and McCormack, B. 1998. Enabling the implementation of evidenced based practice: a conceptual framework. Quality in Health Care, Sep; 7(3), pp. 149-58.

Walsh, K., Lawless, J., Moss, C. and Allbon, C. 2005. The development of an engagement tool for practice development. Practice Development in Health Care, 4(3): 124-130.

Appendix III Nursing Research & Development Unit

The DEEP – Designing an Effective Evaluation Plan

Walsh, Kenneth (DEEP) Designing an Effective Evaluation Plan (formatted (mark1) May 2006)

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Designing an Effective Evaluation Plan (DEEP): 28 questions to help you devise an

effective evaluation plan.

The following questions are designed to help you build an effective evaluation plan.

The puzzle Q1. So you want to evaluate something: what is it? Describe what it is you wish to evaluate. Write this as if you were describing the intervention, new role or program to someone who had no prior knowledge if it. This will help ensure you do not miss out essential elements that may need evaluation. Sometimes we are so close to something the essential elements become less visible because of our familiarity with them. ……………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………… Q2. Is the thing described above an intervention, a new role or a program? This will assist you to decide on the methods of evaluation. An intervention may lend itself to a pre-test post-test design. A program or a new role may use a mixture of qualitative and quantitative measures and a more pluralistic evaluation. …………………………………………………………………………………………………………………………………………………………………………………………………… The purpose Questions 3 to 12 will help you to further refine your thinking around the methods of evaluation and the data to be collected. Remember that health services already collect large amounts of data. It is possible that you may be able to use some of these data sources to assist in your evaluation. Q3. Given your answers to the question 2 above, what is the main purpose of the evaluation?(circle choice) A. Formative: focussed on the design stage of a project to assess the plan and its objectives with the aim of identifying potential issues at a formative stage. B. Process: to identify and describe what takes place in a project in an attempt to understand its strengths and weaknesses. C. Outcomes: investigates the achievement and effectiveness of project/intervention goals. D. Mixed purpose evaluation The evidence Q4. If this intervention, new role or program were successful, how would you know?

Appendix III Nursing Research & Development Unit

The DEEP – Designing an Effective Evaluation Plan

Walsh, Kenneth (DEEP) Designing an Effective Evaluation Plan (formatted (mark1) May 2006)

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…………………………………………………………………………………………………………………………………………………………………………………………………… …………………………………………………………………………………………………………………………………………………………………………………………………… Q5. If the evaluation were completed what would you know that you don’t know now? …………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………… Q6. What data would you need to collect in relation to questions 4 and 5 above? …………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………… Q7. From where would you get this data? …………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………… Q8. What methods would you use to collect this data? …………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………… Q9. What methods would you use to analyse this data? …………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………… Q10. Does the organisation or others already collect any of this data? ……………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………… Q11. At what point would you collect this data? ………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………

Appendix III Nursing Research & Development Unit

The DEEP – Designing an Effective Evaluation Plan

Walsh, Kenneth (DEEP) Designing an Effective Evaluation Plan (formatted (mark1) May 2006)

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Q12. Are there likely to be other indirect outcomes as a result of the intervention, role or program? ……………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………… Q13. How might these outcomes be captured? …………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………… The context Evaluations usually involve multiple stakeholders and the results of evaluations are used for different purposes. Questions 14 to 17 will help you judge why the evaluation is necessary, and the resource you may need to make it happen. It also asks you to consider the ethical implications of undertaking (or not undertaking) the evaluation. Some evaluations may need the approval of an ethics committee but all evaluations must be conducted in an ethical manner. Q14. Why do you need to evaluate this intervention, role or project? …………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………… Q15. What are the consequences of not undertaking the evaluation? ……………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………… Q16. What are the political implications in relation to the evaluation? …………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………… Q17. What resources will you need in order to carry out the evaluation? ……………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………

Appendix III Nursing Research & Development Unit

The DEEP – Designing an Effective Evaluation Plan

Walsh, Kenneth (DEEP) Designing an Effective Evaluation Plan (formatted (mark1) May 2006)

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Q18. How much time and energy can you/your service devote to the process? Thinking about the timing of this proposal, what else is going on in the environment at this time? …………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………… Q19. Do the staff and people in the services that this will involve have the emotional and cultural capacity to cope with the evaluation at this time? …………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………… Q20. What are the ethical implications of this evaluation? …………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………… The facilitation Questions 21-25 ask you to consider your key stakeholders. As mentioned above, evaluations by their very nature involve multiple stakeholders. Failure to identify the key stakeholders who may have an interest in the results of the evaluation or are pivotal to undertaking the evaluation may mean an unsatisfactory outcome for all concerned. Q21. Given your answers thus far, with whom will you need to engage in the evaluation? …………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………… Q22. Make a list of everyone who you think may have an interest in or be pivotal to, the evaluation. This may be services or individuals within services, or clients. It may be people who have access to data, be sources of data or have a political or other interest in the evaluation. List here. 1…………………………………………………………………………… 2…………………………………………………………………………… 3……………………………………………………………………………

Appendix III Nursing Research & Development Unit

The DEEP – Designing an Effective Evaluation Plan

Walsh, Kenneth (DEEP) Designing an Effective Evaluation Plan (formatted (mark1) May 2006)

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4…………………………………………………………………………… 5…………………………………………………………………………… 6……………………………………………………………………………

Q23. Referring to the list of interested people and parties that you identified above: identify the key partners you will need to work with directly as part of the evaluation process. …………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………… Q24. Identify who you will need to engage in consultation during the process. ……………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………

Q25. Identify those you need to keep informed and with whom you will need to establish communications …………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………… Q26. Identify those who may be sources of data ……………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………

Q27. Identify those who may have access to sources of data ……………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………

Q28. Check that you have included everyone listed earlier. If anyone has dropped off your list give reasons why. ………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………

Appendix III Nursing Research & Development Unit

The DEEP – Designing an Effective Evaluation Plan

Walsh, Kenneth (DEEP) Designing an Effective Evaluation Plan (formatted (mark1) May 2006)

6

……………………………………………………………………………………………………………………………………………………………………………………………………

Plan:

We wish to evaluate X …

…………………………………………………………………………………………………

…………………………………………………………………………………………………

…………………………………………………………………………………………………

…………………………………………………………………………………………………

…………………………………………………………………………………………………

in order to ascertain Y …

…………………………………………………………………………………………………

…………………………………………………………………………………………………

…………………………………………………………………………………………………

…………………………………………………………………………………………………

…………………………………………………………………………………………………

The data we wish to collect is

…………………………………………………………………………………………………

…………………………………………………………………………………………………

…………………………………………………………………………………………………

…………………………………………………………………………………………………

…………………………………………………………………………………………………

This will be collected from

…………………………………………………………………………………………………

…………………………………………………………………………………………………

…………………………………………………………………………………………………

Appendix III Nursing Research & Development Unit

The DEEP – Designing an Effective Evaluation Plan

Walsh, Kenneth (DEEP) Designing an Effective Evaluation Plan (formatted (mark1) May 2006)

7

…………………………………………………………………………………………………

…………………………………………………………………………………………………

At …..time

And analysed using

…………………………………………………………………………………………………

…………………………………………………………………………………………………

…………………………………………………………………………………………………

…………………………………………………………………………………………………

…………………………………………………………………………………………………

The report of this evaluation will be disseminated to….

…………………………………………………………………………………………………

…………………………………………………………………………………………………

…………………………………………………………………………………………………

…………………………………………………………………………………………………

…………………………………………………………………………………………………

The timeframe for the evaluation is

…………………………………………………………………………………………………

…………………………………………………………………………………………………

…………………………………………………………………………………………………

…………………………………………………………………………………………………

…………………………………………………………………………………………………

The ethical implications are …

…………………………………………………………………………………………………

…………………………………………………………………………………………………

…………………………………………………………………………………………………

Appendix III Nursing Research & Development Unit

The DEEP – Designing an Effective Evaluation Plan

Walsh, Kenneth (DEEP) Designing an Effective Evaluation Plan (formatted (mark1) May 2006)

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…………………………………………………………………………………………………

…………………………………………………………………………………………………

Appendix IV

The WADULA Puzzling Cube

Workbook

Setting the scene for successful change

WADULA Puzzling Cube Workbook Nursing Research and Development Unit, 2008

Nursing Research & Development Unit Waikato DHB, Hamilton & Victoria University, Wellington, New Zealand

2

Wadula Workbook

Purpose of the workbook

The purpose of the workbook is to support you to take an idea, issue or

initiative from the conceptual stage to the point where you are ready to

take a proposal out to others to engage them in a co-operative process.

What is the WADULA Puzzling Cube? The WADULA Puzzling Cube was developed by the Nursing Research and

Development Unit as a method of managing the early stages of a proposed

change process. The cube covers the areas of; puzzling, clarifying purpose,

evidence, engagement, context, evaluation, facilitation and

implementation.

How to use the workbook

The workbook is designed as a step-by-step process based on a series of

simple exercises. There are no right or wrong answers. The process is

reflective and encourages you to unpack your thinking and identify the steps

that will support a successful process.

WADULA Puzzling Cube Workbook Nursing Research and Development Unit, 2008

Nursing Research & Development Unit Waikato DHB, Hamilton & Victoria University, Wellington, New Zealand

3

Identifying your puzzle You have probably begun with an idea, issue or problem and possibly you

already believe that you know what the solution should be. You may have

also realised that if you try to impose your solution on others who have an

interest in the process and outcome, the odds are that you will meet with

resistance. Solutions don’t solve problems, people do. If you want to take

others with you, it is necessary to take a step back, put aside your own

ideas for now and identify what brought you to this point. This section is

designed to help you clarify your thinking and assists you to identify the

heart of the matter around which you wish to engage.

So what’s your idea/initiative/issue about?

You now need to turn your idea/initiative/issue into a puzzle question. We

suggest using the term ‘puzzle’ rather than words such as ‘issue’ or

‘problem’ as these can imply fault or confrontation and may mobilise

resistance before you even begin. The concept of ‘puzzling’ suggests a more

co-operative effort. Puzzles have a different focus to problems and require

people to think in a different, creative and more positive way. Puzzles are

shared. Seeing problems as puzzles uses our imagination to reframe

something old into something new. We seldom ask ‘whose puzzle is it

anyway?’ We seldom say ‘that’s your puzzle’ and of course we are unlikely

to say ‘who caused the puzzle in the first place?’ Puzzles are often solved

1

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with the help of others and once you have found solutions for one puzzle

other puzzles will often be easier to solve.

Try restating your idea/initiative/issue as a question beginning

“how can we…….?”

The next step in developing your puzzle is to make sure that it is stated in

the way most likely to mobilise the support of others. The way we

articulate puzzles is as ‘positive unconditional generative questions’.

‘Positive’ in the sense that the language you use is not negative or critical

of other parties, ‘unconditional’ requires that there are no preconditions or

solutions put forward at the beginning, ‘generative’ means that the puzzle

requires more than a yes/no response, and ‘question’ refers to the way we

frame the puzzle as a question to be answered.

Check your previous puzzle question to see that it conforms to

this style

• Positive? (doesn’t imply criticism or blame)

• Unconditional? (no solutions hidden in it)

• Generative? (requires more than a yes or no response)

• Question? (framed as a puzzle)

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Clarifying your purpose Now that you have your puzzle question, the next step is to clarify the

purpose behind your thinking. The people that we work with are generally

leading busy lives. If you want your proposal to be favourably received, it is

important that you have given consideration to the purpose behind your

proposal, and equally importantly, how this idea fits with the wider purpose

of the work that you and your team are engaged in.

What would you say is the purpose of your puzzle?

If you were successful in finding a solution to the puzzle, what

would be different and/or better for patients and service

providers?

Our patients would……

Our staff would………

Our service would……….

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How does this puzzle fit with the wider purpose of the work

that you and your team are engaged in – the ‘heart of your

work’?

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Evidence

Justifying your rationale for proposing change

When you take out your proposal to others, even though it is positively

framed and you are clear about the purpose, don’t expect others to join in

without expressing some doubts or scepticism. They may not see things

quite the way that you have. It may also be new to their thinking. It is

important to take the time to look for any evidence you already have that

supports your view that this is something worth spending time on. This

evidence will help confirm that the issue you wish to engage about is in fact

important and it will help when presenting your proposal to others.

What is your evidence to suggest that change might be

indicated?

What do you know about what is happening now?

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Where could you source evidence to support your proposal?

What types of evidence might support your proposal?

How strong is your evidence?

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Engagement

Who else will be interested in this puzzle?

One common mistake that is made that stops co-operative engagement in its

tracks is to jump in enthusiastically without giving consideration to how

others are likely to react. It is worth taking the time to reflect on who

might be interested in your puzzle and who you will need to directly

involve.

Make a list of everyone who you think may have an interest in

knowing about or being involved in your puzzle.

This may be services or individuals within services (including your own) or

clients. It is important that you cast your net wide as these are the

individuals or services that are most likely to contribute to the success of, or

be affected by, the potential outcomes. These people are potentially both

your biggest allies and your biggest critics.

………………………………………………….. ……………………………………………………

………………………………………………….. ……………………………………………………

………………………………………………….. …………………………………………………….

………………………………………………….. …………………………………………………….

………………………………………………….. …………………………………………………….

………………………………………………….. …………………………………………………….

………………………………………………….. …………………………………………………….

………………………………………………….. …………………………………………………….

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Of the people on your list;

• identify the key partners you will need to work with directly as part

of the engagement process

• identify who you will need to engage in consultation during the

process

• identify those you need to keep informed and with whom you will

need to establish communications

• check that you have included everyone listed earlier. If anyone has

dropped off your list give reasons why

• Put a tick beside those people who you think will be supportive to

your proposal

• Put a question mark beside any people who you think may react

negatively to your proposal

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Is it your impression that the parties will be approaching the

engagement with an intention to succeed?

Do you think there will be any preconditions to engaging with

you? (e.g. this won’t be supported if it involves extra

resources or increased workload).

Consider your own attitude. Do you already have a solution in

mind?

If yes, how attached do you feel to this particular solution? Remember that

you are committed to finding a solution to the puzzle, not your particular

solution. Working together opens the possibility that even better solutions

may emerge.

Have you previously tried to engage around this or something

similar?

If so is this already a “hot” issue amongst some of the parties?

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Are there any other questions that you have thought of related

to engagement?

Having reflected on the people who are likely to be interested

and/or involved, summarise your thoughts about the positive

and negative aspects

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Context

Evaluating the readiness for change at this time

You’ve now thought about the people you will be engaging with. This

section looks at the environment in which engagement around change will

take place and helps you identify the current capacity and resource

available that may affect your proposed engagement.

How much time and energy can you/your service devote to the

process? Thinking about the timing of this proposal, what else is going on

in the environment at this time?

Do the staff and people in the services that this will involve

have the emotional and cultural capacity to cope with this

puzzle at this time?

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Do you think that the evidence/proposal will be seen as

applicable to your context? Use the FAME rating

Is what you are proposing Feasible?

Would what you are proposing be seen as Acceptable?

Would others regard what you are proposing as Meaningful?

Would what you are proposing be Effective

Have you thought about any other questions relating to the

current context?

If your analysis showed you that the environment and people are not well

placed to cope with this proposal at this time, we are not suggesting that

you don’t take it forward but you may need to identify what needs to

happen before you introduce the proposal.

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Evaluation

How will you measure change?

Giving thought to how your puzzle could be evaluated is something that is

often left until late in the process. There are some obvious problems with

this. Considering evaluation options at the beginning of the process not only

makes the journey easier, but is also reassuring to others that you may wish

to engage in the puzzle, as it shows that you have been thorough and

thoughtful.

How will you know that any change has made a difference?

• To patients

• To staff

• To the service

What data will you need to collect to know this?

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Where might you get this data from?

What data are you already collecting?

At the end, what will you know that you don’t know now?

Do you have any other questions relating to evaluation?

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Facilitation Mobilising co-operation rather than resistance

Given what you now know, it is time to consider what will be involved in

getting this puzzle off the ground and whether you think that you have the

skills to take the proposal forward.

What have you learned about the way you will need to

facilitate the engagement process?

What do you know about the ways people in your team and the

team’s you need to engage with generally respond to proposed

change?

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Would it be useful to seek advice/support – if yes, from whom?

What methods do you think would be most effective to

communicate your puzzle to others in a way that will mobilise

support?

Do you have any other thoughts or questions relating to

facilitating the process?

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Implementation

Identifying the actions that will give you the greatest

chance of success with your puzzle

What specific actions have you identified (relating to the

people who will be involved) that you need to act upon prior

to taking your puzzle out?

Are there people/services identified where it would be

beneficial to undertake some relationship building/rebuilding

before launching your puzzle? If yes, what action could you

take to achieve this?

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What specific actions have you identified relating to the

environment and resources that you need to address prior to

taking your puzzle out?

What is the key message you wish to take to your identified

partners? This should be a message of engagement and working

collaboratively. It must not prescribe a solution.

Try framing up a statement of engagement using the following

template.

“We would like to discuss with you how we may work together around a

proposal to ……………………..

with a view to achieving……………………………………

The reason for undertaking this proposal is.........

and we hope that working together we may be able to generate a solution

which is beneficial to us all and the clients for whom we care.”

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How will you communicate this message to everybody that you

identified as having an interest or stake in this proposal? You

will need to invite them to state what level of involvement in the process

they would wish. This will range from active involvement to being consulted

at key points, providing advice or simply being kept informed.

Developing your puzzle proposal using the material

from the workbook.

Ideally this should be no more than two or three pages and should use the

key points that you have uncovered during the reflective process.

We are proposing to engage around the puzzle of ‘how can

we……’

The purpose of engaging around this puzzle is to……………………

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We hope that by finding solutions for this puzzle, our patients,

staff and service would benefit in the following ways…….

The evidence that we have to support our belief that this

puzzle is important is……………………………………..

Evidence that we still need to collect

includes……………………………..

The people/services that we have identified as most important

to this puzzle are……………………………………………………..and we

think that we will need to engage directly

with…………………………………….to seek solutions for this puzzle

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We have identified the following features of the current

context as being important to supporting the

puzzle…………………..

We have identified the following features of the current

context as potentially getting in the way of successful

engagement with this puzzle………………

We propose evaluating any changes generated through the

process by………..

In order to facilitate the initial engagement of key

stakeholders with the puzzle, we will communicate the puzzle

by……………..

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References

Walsh K, Lawless J, Moss C, and Allbon C. (2005) The development of an engagement tool for practice development. Practice Development in Health Care, 4(3): 124-130. Walsh K, McAllister M, Norgan A, and Thornhill J, (2004), Motivating Change: Using motivational interviewing in practice development. Practice Development in Health Care, 3(2): 92-100. Kitson A, Harvey G and McCormack B. (1998), Enabling the implementation of evidence based practice: A conceptual framework. Quality in Health Care, 7(3): 149-158. Rycroft-Malone J, Harvey G, Seers K, Kitson A, McCormack B and Titchen A. (2004) An exploration of the factors that influence the implementation of evidence into practice. Journal of Clinical Nursing. 13(8):913-924

Appendix VI

1

PEBBLES/KOHATU PROGRAMME EVALUATION

Thank you for taking the time to complete this survey. The survey is part of the information gathering phase we are using to evaluate the Pebbles and Kohatu Programmes. The data collected from this survey form will remain confidential. Completed evaluation forms will be analysed by some of the researchers attached to this project. Individuals involved in facilitating the Programmes will not be shown this information. When the evaluation has been completed, the final report will be made available to all research participants. The purpose of this survey is to capture your thoughts and ideas about the Pebbles and Kohatu Programmes – what worked well and perhaps what could have worked better. The information gathered from this questionnaire will be used to inform and develop future Programmes. The survey should take about 10 minutes to complete. We recommend that you complete the survey on your own so that your views are clearly represented. Please place the completed surveys in the self-addressed envelope attached. The last date for surveys to be returned is Thursday 30 September 2010. Approval for this research project has been received from the Northern Y Regional Ethics Committee (Ref: NTY/10/06/054). If you have any queries regarding this questionnaire or the evaluation process please contact: Philippa Miskelly (PhD) Research Fellow, Professional Development Unit Email: philippa.miskelly@waikatodhb.health.nz phone: (07) 839-8899 ext. 23406

PERSONAL INFORMATION Age: (please tick one): 20-30 ……. 31-40 ……. 41-50 ……. 51+ ……. Male/Female: (please circle one) Ethnicity: …………………………… NZ Trained/Overseas Trained: (please circle one) Post-reg qualification(s) (please list): ………………………………………...................... PDRP level achieved prior to Programme? …………………….. PDRP level achieved since Programme? ………………………. How many years since you became a registered nurse? ………………………… Attended Pebbles/Kohatu Programme: (please circle one) Year attended Programme: ……………………………… Your role when you participated in Pebbles/Kohatu Programme (eg: ward RN, nurse educator etc):

…………………………………..

Ward/Unit you worked in when you were undertaking Pebbles/Kohatu Programme: ……………….. Current role: (please describe eg: nurse educator, ward RN etc.): …………………………………… Ward/Unit you are currently working in: ……………………………………………..

Appendix VI

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This questionnaire uses a Likert scale format. While there are many descriptions that could be used to express opinions, the following ones have been chosen: strongly disagree, disagree, mainly disagree, undecided, mainly agree, agree and strongly agree. Please circle ONE response per question. PEBBLES/KOHATU PROGRAMME

1. The Programme gave me an opportunity to reflect on my practice

1 2 3 4 5 6 7 |----------------------|------------------|----------------|----------------|---------------|------------------|

Strongly disagree Disagree Mainly Disagree Undecided Mainly agree Agree Strongly Agree

2. I found each session of the Programme useful

1 2 3 4 5 6 7 |----------------------|------------------|----------------|----------------|---------------|------------------|

Strongly disagree Disagree Mainly Disagree Undecided Mainly agree Agree Strongly Agree

3. The format of the Programme worked well

1 2 3 4 5 6 7 |----------------------|------------------|----------------|----------------|---------------|------------------|

Strongly disagree Disagree Mainly Disagree Undecided Mainly agree Agree Strongly Agree

4. The Programme was relevant to my work

1 2 3 4 5 6 7 |----------------------|------------------|----------------|----------------|---------------|------------------|

Strongly disagree Disagree Mainly Disagree Undecided Mainly agree Agree Strongly Agree

5. I easily understood the ideas discussed throughout the Programme

1 2 3 4 5 6 7 |----------------------|------------------|----------------|----------------|---------------|------------------|

Strongly disagree Disagree Mainly Disagree Undecided Mainly agree Agree Strongly Agree

6. The presenters/guest speakers provided worthwhile information

1 2 3 4 5 6 7 |----------------------|------------------|----------------|----------------|---------------|------------------|

Strongly disagree Disagree Mainly Disagree Undecided Mainly agree Agree Strongly Agree

7. I was able to complete the homework tasks each month

1 2 3 4 5 6 7 |----------------------|------------------|----------------|----------------|---------------|------------------|

Strongly disagree Disagree Mainly Disagree Undecided Mainly agree Agree Strongly Agree

Appendix VI

3

8. I would have liked different topics included in the Programme

1 2 3 4 5 6 7 |----------------------|------------------|----------------|----------------|---------------|------------------|

Strongly disagree Disagree Mainly Disagree Undecided Mainly agree Agree Strongly Agree

9. The Programme was what I expected

1 2 3 4 5 6 7 |----------------------|------------------|----------------|----------------|---------------|------------------|

Strongly disagree Disagree Mainly Disagree Undecided Mainly agree Agree Strongly Agree

10. It was easy to discuss ideas with the other people attending the Programme

1 2 3 4 5 6 7 |----------------------|------------------|----------------|----------------|---------------|------------------|

Strongly disagree Disagree Mainly Disagree Undecided Mainly agree Agree Strongly Agree

11. The Programme helped me to establish the purpose of my work

1 2 3 4 5 6 7 |----------------------|------------------|----------------|----------------|---------------|------------------|

Strongly disagree Disagree Mainly Disagree Undecided Mainly agree Agree Strongly Agree

12. I clearly understand what evidence-based knowledge means in relation to my work

1 2 3 4 5 6 7 |----------------------|------------------|----------------|----------------|---------------|------------------|

Strongly disagree Disagree Mainly Disagree Undecided Mainly agree Agree Strongly Agree

13. At times I felt it was difficult to express my opinions within the group

1 2 3 4 5 6 7 |----------------------|------------------|----------------|----------------|---------------|------------------|

Strongly disagree Disagree Mainly Disagree Undecided Mainly agree Agree Strongly Agree

14. Meeting nurse leaders during the Programme has provided me with a better understanding of their roles and responsibilities

1 2 3 4 5 6 7 |----------------------|------------------|----------------|----------------|---------------|------------------|

Strongly disagree Disagree Mainly Disagree Undecided Mainly agree Agree Strongly Agree

15. The Programme helped me find a mentor

1 2 3 4 5 6 7 |----------------------|------------------|----------------|----------------|---------------|------------------|

Strongly disagree Disagree Mainly Disagree Undecided Mainly agree Agree Strongly Agree

Appendix VI

4

16. The Programme provided me with access to professional support

1 2 3 4 5 6 7 |----------------------|------------------|----------------|----------------|---------------|------------------|

Strongly disagree Disagree Mainly Disagree Undecided Mainly agree Agree Strongly Agree CLINICAL PRACTICE

17. My CNM provided ongoing support while I was involved in the Programme

1 2 3 4 5 6 7 |----------------------|------------------|----------------|----------------|---------------|------------------|

Strongly disagree Disagree Mainly Disagree Undecided Mainly agree Agree Strongly Agree

18. I understood my CNM’s expectations in relation to my attendance at the Programme

1 2 3 4 5 6 7 |----------------------|------------------|----------------|----------------|---------------|------------------|

Strongly disagree Disagree Mainly Disagree Undecided Mainly agree Agree Strongly Agree

19. My clinical colleagues were supportive of my attendance at the Programme

1 2 3 4 5 6 7 |----------------------|------------------|----------------|----------------|---------------|------------------|

Strongly disagree Disagree Mainly Disagree Undecided Mainly agree Agree Strongly Agree

20. I have changed some aspects of my clinical practice since attending the Programme

1 2 3 4 5 6 7 |----------------------|------------------|----------------|----------------|---------------|------------------|

Strongly disagree Disagree Mainly Disagree Undecided Mainly agree Agree Strongly Agree

21. I have a better understanding of the DHB since attending the Programme

1 2 3 4 5 6 7 |----------------------|------------------|----------------|----------------|---------------|------------------|

Strongly disagree Disagree Mainly Disagree Undecided Mainly agree Agree Strongly Agree

22. I am now prepared to work as a Preceptor

1 2 3 4 5 6 7 |----------------------|------------------|----------------|----------------|---------------|------------------|

Strongly disagree Disagree Mainly Disagree Undecided Mainly agree Agree Strongly Agree

23. Since attending the Programme I use the library more frequently to access information that might help with my clinical practice

1 2 3 4 5 6 7 |----------------------|------------------|----------------|----------------|---------------|------------------|

Strongly disagree Disagree Mainly Disagree Undecided Mainly agree Agree Strongly Agree

Appendix VI

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24. I clearly understood the purpose of the Programme

1 2 3 4 5 6 7 |----------------------|------------------|----------------|----------------|---------------|------------------|

Strongly disagree Disagree Mainly Disagree Undecided Mainly agree Agree Strongly Agree CAREER

25. The Programme helped me to stay within my clinical environment

1 2 3 4 5 6 7 |----------------------|------------------|----------------|----------------|---------------|------------------|

Strongly disagree Disagree Mainly Disagree Undecided Mainly agree Agree Strongly Agree

26. The Programme helped me to make changes to my work environment

1 2 3 4 5 6 7 |----------------------|------------------|----------------|----------------|---------------|------------------|

Strongly disagree Disagree Mainly Disagree Undecided Mainly agree Agree Strongly Agree

27. The Programme helped me to change my job/my role

1 2 3 4 5 6 7 |----------------------|------------------|----------------|----------------|---------------|------------------|

Strongly disagree Disagree Mainly Disagree Undecided Mainly agree Agree Strongly Agree

28. The Programme influenced me to continue with/take-up post-graduate study

1 2 3 4 5 6 7 |----------------------|------------------|----------------|----------------|---------------|------------------|

Strongly disagree Disagree Mainly Disagree Undecided Mainly agree Agree Strongly Agree LEADERSHIP

29. Pebbles/Kohatu provided me with information about leadership skills

1 2 3 4 5 6 7 |----------------------|------------------|----------------|----------------|---------------|------------------|

Strongly disagree Disagree Mainly Disagree Undecided Mainly agree Agree Strongly Agree

30. I now have more contact with nursing leaders

1 2 3 4 5 6 7 |----------------------|------------------|----------------|----------------|---------------|------------------|

Strongly disagree Disagree Mainly Disagree Undecided Mainly agree Agree Strongly Agree

31. I now feel confident about talking with nursing leaders

1 2 3 4 5 6 7 |----------------------|------------------|----------------|----------------|---------------|------------------|

Strongly disagree Disagree Mainly Disagree Undecided Mainly agree Agree Strongly Agree

Appendix VI

6

32. I would like more contact with nursing leaders

1 2 3 4 5 6 7 |----------------------|------------------|----------------|----------------|---------------|------------------|

Strongly disagree Disagree Mainly Disagree Undecided Mainly agree Agree Strongly Agree

33. I have applied/plan to apply for a nurse educator/clinical nurse leadership role

1 2 3 4 5 6 7 |----------------------|------------------|----------------|----------------|---------------|------------------|

Strongly disagree Disagree Mainly Disagree Undecided Mainly agree Agree Strongly Agree

34. I have applied/plan to apply for a non-clinical nurse leadership position

1 2 3 4 5 6 7 |----------------------|------------------|----------------|----------------|---------------|------------------|

Strongly disagree Disagree Mainly Disagree Undecided Mainly agree Agree Strongly Agree

35. I would like more leadership training/education

1 2 3 4 5 6 7 |----------------------|------------------|----------------|----------------|---------------|------------------|

Strongly disagree Disagree Mainly Disagree Undecided Mainly agree Agree Strongly Agree PRACTICE DEVELOPMENT

36. I understand what Practice Development is

1 2 3 4 5 6 7 |----------------------|------------------|----------------|----------------|---------------|------------------|

Strongly disagree Disagree Mainly Disagree Undecided Mainly agree Agree Strongly Agree

37. Practice Development now helps me within my clinical environment

1 2 3 4 5 6 7 |----------------------|------------------|----------------|----------------|---------------|------------------|

Strongly disagree Disagree Mainly Disagree Undecided Mainly agree Agree Strongly Agree

38. Practice Development has changed the way I communicate with my colleagues

1 2 3 4 5 6 7 |----------------------|------------------|----------------|----------------|---------------|------------------|

Strongly disagree Disagree Mainly Disagree Undecided Mainly agree Agree Strongly Agree

39. I discuss Practice Development with my clinical colleagues

1 2 3 4 5 6 7 |----------------------|------------------|----------------|----------------|---------------|------------------|

Strongly disagree Disagree Mainly Disagree Undecided Mainly agree Agree Strongly Agree

Appendix VI

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Any other comments you would like to make about the Pebbles or Kohatu Programmes: _______________________________________________________________________________ _______________________________________________________________________________

_______________________________________________________________________________ _______________________________________________________________________________

_______________________________________________________________________________ _______________________________________________________________________________

_______________________________________________________________________________ _______________________________________________________________________________

_______________________________________________________________________________ _______________________________________________________________________________

_______________________________________________________________________________ _______________________________________________________________________________

_______________________________________________________________________________ _______________________________________________________________________________

_______________________________________________________________________________ _______________________________________________________________________________

_______________________________________________________________________________ _______________________________________________________________________________

_______________________________________________________________________________ _______________________________________________________________________________

_______________________________________________________________________________ _______________________________________________________________________________ _______________________________________________________________________________ _______________________________________________________________________________

Thank you for taking the time to complete this questionnaire

3/11/2011 Version 1

APPENDIX VII

PEBBLE / KOHATU PARTICIPANT FOCUS GROUP AND INDIVIDUAL INTERVIEWS

DRAFT INTERVIEW GUIDE (prompts only)

• You’ve all [you have] been involved in the Pebbles / Kohatu programme. Can you describe to me your expectations of the programme?

• Were your expectations realised?

• What were the good things about the programme?

• What about things that weren’t so good? • What impact did the programme have on your work environment?

• What impact did the programme have on your nursing practice?

• Can you describe to me the things you learned from the programme?

• What would you identify as the three most significant aspects you gained from

being able to be part of a Pebbles / Kohatu programme?

• Has being involved in the programme changed your views about your job?

• Has being involved in the programme changed your views about the way patient care is delivered in your ward or unit?

• If so, have you been able to influence any changes you think might be needed?

• How do you feel your colleagues thought about you being on the Pebbles /

Kohatu programme?

• If you had to describe the value of the programme to this organisation, what would you say?

• What changes, if any, has the programme made to the way you see your nursing

career progressing?

• What skills do you think nurses need to help them step up to leadership positions? I’m not talking just about clinical nurse manager or even nursing manager roles, but nurses who are prepared to lead projects within their ward or unit environments, or who are willing to preceptor students or graduate nurses?

• Any other questions or comments that you would like to make?

A PLURALISTIC EVALUATION OF THE PEBBLES/KOHATU NURSING LEADERSHIP

PROGRAMMES

3/11/2011 Version 1

APPENDIX VIII

PEBBLE / KOHATU CLINICAL NURSE MANAGER FOCUS GROUP INTERVIEWS

DRAFT INTERVIEW GUIDE (prompts only)

• You’ve all had nurses who have been involved in the Pebbles /Kohatu programmes. What were your expectations of the programme?

• Were your expectations realised?

• Any changes you’d like to suggest?

• Why did the particular nurses from your ward/unit go on the programme?

• Did these nurses show particular attributes – and what were these?

• What, if any, impact do you think the programme had on your ward/unit?

• What, if any, impact do you think the programme had on the participants themselves?

• What would you identify as the three most significant aspects you think your

ward/unit gained from having a member of staff be involved with the Pebbles or Kohatu programmes?

• Has having a staff member being involved in the programme changed any aspects

related to the way patient care is delivered in your ward or unit?

• How do you feel other staff members have thought about their colleague being on the Pebbles / Kohatu programme?

• If you had to describe the value of the programme to this organisation, what

would you say?

• What skills do you think nurses need to help them step up to leadership positions? I’m not talking just about clinical nurse manager or even nursing manager roles, but nurses who are prepared to lead projects within their ward or unit environments, or who are willing to preceptor students or graduate nurses?

• Any other questions or comments that you would like to make?

A PLURALISTIC EVALUATION OF THE PEBBLES/KOHATU NURSING LEADERSHIP

PROGRAMMES

Appendix IX

A PLURALISTIC EVALUATION OF THE PEBBLES/KOHATU NURSING LEADERSHIP PROGRAMMES

INFORMATION SHEET SUMMARY

• You are invited to participate in an evaluation of the above programme.

• If you agree to participate, you can withdraw at any stage. You also do not have to answer all questions and can request that certain information not be used.

• The project is being evaluated by researchers based at the Professional Development Unit, Waikato District Health Board/Victoria University as well as at Monash and Wollongong Universities in Australia.

• This research is aimed at finding out your opinions about being involved with the Pebbles/Kohatu Nursing Leadership Programmes.

• Questionnaires have been sent to all programme participants. Focus groups interviews are being held with the facilitators who set up and run the programmes, as well as some of the nurses who have participated in the programmes and also with some of the clinical nurse managers whose staff have been involved with the programmes.

• Individual interviews with some of the nurses who have participated in the Pebbles and Kohatu Programmes will also be undertaken.

• Focus groups will last for approximately one hour.

• Individual interviews will last between 45 minutes to one hour. All information that is shared during an interview will be treated as confidential. However, it should be noted that while confidentiality is encouraged in focus groups it cannot be guaranteed.

• This research project has been approved by the Northern Y Regional Ethics Committee.

Appendix IX

A PLURALISTIC EVALUATION OF THE PEBBLES/KOHATU NURSING LEADERSHIP PROGRAMMES

INFORMATION SHEET Principal Researcher Dr Philippa Miskelly (PhD, BSocSc Hons) Research Fellow Professional Development Unit (PDU), Waikato District Health Board/ Graduate School of Nursing, Midwifery & Health Victoria University of Wellington Co-Researchers Mrs Lindsay Duncan, Nurse Co-ordinator Practice Development, c/- Professional Development Unit, Waikato District Health Board Dr Cheryle Moss, Associate Professor Nursing, Research & Practice Development, Monash University, Melbourne, Australia Dr Ken Walsh, Professor of Nursing Practice Development, Wollongong University, Australia Professor Wendy Cross, Head of School, School of Nursing & Midwifery, Monash University, Melbourne, Australia Dr Kay McCauley-Elsom, Senior Lecturer, School of Nursing & Midwifery, Monash University, Melbourne, Australia Research Commissioned By Professional Development Unit, Waikato District Health Board

Invitation to Participate in Evaluation You are invited to take part in an evaluation relating to your experiences of the Pebbles/Kohatu Nursing Leadership Programmes. Your participation would involve completing a questionnaire and may also include taking part in a focus group interview which will last for approximately one hour, and/or an individual interview which will last between 45 minutes to an hour. Interviews and focus groups will be conducted, in private, by Philippa Miskelly, in the meeting room at Percival Flats, Waikato Hospital. During the focus groups/interviews you will be asked to share your thoughts about the Pebbles/Kohatu Nursing Leadership Programme that you participated in. You have the right to:

• Refuse to answer any question(s) and to withdraw from the study at any time. • Ask questions about the research during the course of the project. • Ask that certain information not be used.

Please note that you do not have to take part in this evaluation as participation is entirely voluntary. Deciding not to take part in the project will not jeopardise your employment status with the Waikato District Health Board nor in any way have a negative impact on your current position within the ward/unit you work in.

Appendix IX

Questionnaires will be forwarded to you and they can be returned in the stamped addressed envelope provided. The focus group will be tape-recorded (with your permission) and transcribed by a research typist. The information will be stored on a computer to enable analysis of the data. Once this has been completed the results will be incorporated into an evaluation report. All research participants, the Waikato DHB’s Kaumatua Kaunihera Research Subcommittee, the Northern Y Regional Ethics Committee along with the major stakeholder, the Professional Development Unit (Waikato DHB) will receive a copy of this report. Part of the research material may also be used in articles for publication. All information will be treated as confidential and your anonymity in reports and publications will be protected. However, it should be noted that while confidentiality is encouraged in focus groups it cannot be guaranteed. Only the Principal Researcher, co-researchers (except for Lindsay Duncan) and the research typist will have access to the information you provide in the interviews, focus group and questionnaire. The transcriptions will not reveal your name or other personal details that could identify you. The tapes and other information will be kept in a secure location which will only be accessible to the researchers. All information will be stored on computer and will only be accessible to the researchers via the use of passwords. No material which could personally identify you will be used in any reports about this study. This research has been approved by the Northern Y Regional Ethics Committee. If you have any questions or concerns about your rights as a participant in this research study you can contact an independent health and disability advocate. This a free service provided under the Health and Disability Commissioner Act. Contact details are: Telephone: (NZ wide) 0800-555-050 Free Fax: (NZ wide) 0800-2787-7678 (0800 2 SUPPORT) Email: (NZ wide) advocacy@hdc.org.nz Introduction This research aims to collect information from a number of people who have been involved with the Pebbles/Kohatu Nursing Leadership Programmes. A questionnaire will be distributed to all nurses who have participated in the programme over the four years. Focus group interviews will also be conducted with programme participants, clinical nurse managers who have had nurses from their wards/units attend Pebbles/Kohatu as well as nurse co-ordinators who have set up and facilitated the programmes. Some individual face-to-face interviews will also be held with Pebbles/Kohatu participants. The questionnaire, focus groups and face-to-face interviews will be used in order to collect information that will inform an evaluation of the Pebbles/Kohatu Nursing Leadership Programmes. The aim of this research is to evaluate the programmes from the perspective of those who have set up and facilitated the course as well as those who have participated in the programme either as a nurse or clinical nurse manager.

Appendix IX

Background The Pebbles programme was set up in 2007, and the first Kohatu programme delivered in 2008. Four Pebbles programmes have been completed between 2007 and 2009, and a fifth one is currently in progress. One Kohatu programme, which has been designed specifically for Maori nurses) has been completed (2008) and another will be run later in 2010. In total, 61 nurses have now taken part (or are currently taking part) in these programmes. Pebbles was set up by the then Nursing Research & Development Unit (NRDU), which has been superseded by the Professional Development Unit. The underlying philosophy of the NRDU was to use Practice Development (PD) ideas and methods to encourage nurses to look at their work environment with ‘fresh eyes’ and provide them with tools to make changes which would enhance and improve patient care and also their own work satisfaction levels. In general, nurses were nominated to attend these programmes by their clinical nurse managers. One criteria for inclusion was that participants were considered to possess attributes which would enable them to develop leadership/mentoring skills. It is now considered timely that the Programme to date be evaluated. We are interested in tracking the career trajectory of participants and finding out their thoughts about the programme – what was good about it and what might need changing. The research team are also interested in whether participants have been able to influence changes within their ward/unit environment in relation to patient care as well as changes they may have made to their own nursing practice and career choices. Participation in Evaluation Your participation could involve one/two or all of the following data collection methods:

1. A questionnaire will be forwarded to all Pebbles/Kohatu participants for completion and return.

2. Seven focus groups will be held. These will comprise two held with clinical nurse managers; three with Pebble participants; one with Kohatu participants and one with Pebble facilitators.

3. Six individual face-to-face interviews will be held with participants drawn from the Pebbles/Kohatu programmes.

During the focus groups/individual interviews you will be asked about your perceptions of the programme, what has been learned from it and whether it has had any influence about on patient care as well as the general work environment. We are also interested to learn whether or not the programmes have impacted or influenced the career paths of participants.

Thank you for agreeing to take part in this research.