© RCN Institute Practice Development Function
RCN INSTITUTE PRACTICE DEVELOPMENT
Transforming individuals and contexts of care
The RCNI Practice Development team offers long-standing expertise in facilitating
cultural change across healthcare organizations at all levels and with all groups of
healthcare staff. The following information outlines a range of tools and processes we
frequently use, plus continue to develop and refine, as a key element of our work.
TOOLS & PROCESSES FOR CULTURAL CHANGE AND ITS EVALUATION
1. General Tools: used to understand, develop and evaluate an effective workplace
culture (defined as ‘the way things are done around here’).
Staff Stories – to understand the culture as experienced by staff
 Learning package
 Guideline for taking patient stories covering:
 Ethical and moral issues/ Informed consent
 Preparation of staff and patients
 Analysis
 Feedback to clinical teams
 Action planning
Observations of Practice/Care - to understand the culture as observed by those
working in the area and external observers
 Guideline for taking patient stories covering:
 Role of observers
 Consent
 Feedback
Patient Stories – to understand the patient experience, learn from it and act on it
 Learning package
 Guideline for taking patient stories covering:
 Ethical and moral issues/ Informed consent
 Preparation of staff and patients
 Analysis
 Feedback to clinical teams
 Action planning
Stakeholder Evaluation
 Acknowledging all stakeholder feedback ( patients, staff, public) using
Claims, Concerns and Issues
 Take action to address the concerns and questions stakeholders have
Workplace Standards for Clinical Teams: Four Standards that can be used as:
 a framework for gathering and structuring evidence that shows that the
workplace is person-centred, effective and evidence-based
 an assessment tool to identify priorities for development work
 part of a development programme for improving the quality of care
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© RCN Institute Practice Development Function
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an evaluation tool to benchmark/monitor progress
a framework for putting into practice shared governance
to demonstrate new ways of working
to help the workplace recruit, develop and retain its staff
Qualitative 360 degree review feedback: The systematic collection, analysis and
feedback of performance data on an individual or group, derived from a number
of the stakeholders on their performance (Manley et al 2004).
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360 review package
Guidelines for seeking feedback
Analysing your feedback
Developing a Personal Development Plan from feedback
Values Clarification Exercise:A tool used for developing a common shared vision
and purpose. It can be used for fostering a common vision in developing, among
other things (Warfield & Manley 1990):
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Role definitions,
Competency or curriculum frameworks, or
Strategic direction for different purposes.
Role analysis: This tool is used to clarify and negotiate roles and role boundaries
(Binnie & Titchen 1999).
Concept analysis: This tool helps stakeholders to develop a common vision about
some aspect of the culture
2. Cultural facilitation tools: to develop expertise in facilitating cultural change towards
an effective workplace culture. These tools help individuals to develop the expertise for
facilitating cultural change using the tools and processes outlined in this appendix
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Facilitation Standards for Individuals
Seven Standards and elements of competence for professional accreditation of
facilitation practice describing
The attributes, qualities, knowledge and skills required for effective one-toone and group facilitation
Group dynamics and processes
The outcomes of effective facilitation
3. Effectiveness Tools: for maintaining and sustaining a culture of effectiveness
Indicators of team effectiveness (due to be piloted December 2004)
Offers a framework to identify and develop team working practices, maximise
team effectiveness and track how team process might impact on person orientated
outcomes
Performance Against Strategic plans
A framework to help teams identify an action plan and monitor progress towards
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© RCN Institute Practice Development Function
objectives
 Action planning – tools to support
 Developing SMART objectives
 Involving all members of the team
Giving and receiving feedback tool
Identifies how to offer feedback and how to make sense and utilise feedback to
improve and sustain effective practice. Can be used for individuals and/or teams.
4. Cultural indicators: These include more specific tools for understanding, developing
and evaluating culture.
Indicators of person-centredness (under development)
A framework that enables practitioners to identify the where, how and why of
person centredness. Campbell et al (2000) define how quality health care has most
meaning when applied to the individual user of health care which they describe as
maximising health benefit according to need.
Specific tools for understanding, developing and evaluating an evidence-based culture
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Research into Child Health (RiCH) Evidence Base Benchmark (Fox &
Feasey,2001)
An example of a specific benchmarking tool that we have discovered can be
used in any healthcare setting (not child specific) for developing and
evaluating the research culture. It provides a structured approach to
encouraging practice that is evidence based. The tool consists of eleven
factors essential for successful research utilisation
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Guideline Evaluation: Appraisal of Guidelines for Research Evaluation
(AGREE) tool (Agree Collaboration, 2001)
This is a tool that help staff to critique the utility and transferability of
evidence-based guidelines to their everyday work
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Essence of Care: Patient Focused Benchmarks for Clinical Governance (DoH
2001)
Nine fundamental aspects of care derived from what patients consider
important
5. Promoting a workplace culture of effectiveness: Processes used to develop and
evaluate an effective workplace culture and simultaneously generate theoretical
understandings
Emancipatory Action Research
A research process concerned with dismantling the barriers to cultural change and
addressing contradictions between the espoused and actual culture as well as
paradoxes and dilemmas in the world of healthcare practice
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© RCN Institute Practice Development Function
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Continuous spirals of reflection, planning action/implementation, evaluation
and reflection
Enable practitioners to learn, develop and become empowered and become
researchers of their own practice
Fourth Generation Evaluation (Guba & Lincoln, 1989)
Guba and Lincoln offer a more informed and sophisticated approach to evaluation
beyond an exclusively scientific notion to include the human, political, social,
cultural, and contextual elements that are involved. Fourth generation evaluation
unites the evaluator with stakeholders in an interaction that creates the product of the
evaluation. Differing from previously existing generations, this new approach moves
evaluation to a new level, whose key dynamic is negotiation.
Realistic Evaluation (Pawson & Tilley, 1997)
Realistic Evaluation reflects the paradigms of scientific realist philosophy and its
commitment to the idea that programs deal with real problems rather than mere social
constructions. Its primary intention is to inform realistic developments in
policymaking that benefits program participants and the public.
Action Learning (McGill & Beaty,2001)
A process for individuals to learn through using group processes to facilitate
reflection in and on action. This approach is used often in conjunction with action
research approaches. A group of people work together for a concentrated period of
time in a continuous process of learning and reflection. Progress through action
research cycles enables lessons learnt en route to be immediately implemented, as
greater understanding of participants’ issues emerge.
Critical Companionship (Titchen, 2001)
Critical companionship is a metaphor for a helping relationship, in which a critical
companion accompanies another person on an experiential journey of learning and
discovery. Our work has shown that critical companionship is effective in helping
practitioners to:
 develop expertise in person-centred practice
 articulate their own professional craft knowledge and its relationship
with theoretical knowledge, research findings and patients’ own
experiences, concerns and preferences,
 critically evaluate their practice,
 generate new knowledge from practice through critique
 become facilitators of experiential learning
Our website address, which includes more examples of our work, can be found at:
http:www.rcn/practicedevelopment/home.php
Alternatively contact: Jo.Odetola@rcn.org.uk
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© RCN Institute Practice Development Function
References
Binnie A & Titchen A (1999) Freedom to practice: The development of patient centred
nursing. Butterworth Heinemann, Oxford.
Campbell SM, Roland MO, Buetwo SA (2000) Defining quality of care. Social Science
and Medicine 51 (11) 1611-1625
Guideline Evaluation: Appraisal of Guidelines for Research Evaluation (AGREE) tool
Agree Collaboration, 2001
Guba E. & Lincoln Y. (1989) Fourth Generation Evaluation. Sage. Newbury Park, Ca.
Fox C & Feasey S (2001) RCN Research into Child Health Group. Evidence Based Care
Benchmark. Royal College of Nursing.
Essence of Care: Patient Focused Benchmarks for Clinical Governance (DoH 2001)
Manley K, Hardy S E, Garbett R, Titchen A & McCormack B (2004) Changing patients’
worlds through nursing practice expertise. A research report. Royal College of Nursing
Institute, London.
McGill I. & Beatty L. (2001) Action Learning: A guide for professional, management &
educational development. Kogan Page. London.
Pawson R. & Tilley N. (1997) Realistic Evaluation. Sage. London.
Titchen, A. (2001). Critical companionship: a conceptual framework for developing
expertise. Practice Knowledge and Expertise in the Health Professions. A. Higgs and A.
Titchen. Oxford, Butterworth Heinemann
Warfield & Manley K (1990) Nursing development unit: developing a new philosophy in
the NDU.Nursing Standard . Jul 4-11;4(41):27-30.
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