Journal of Advanced Nursmg, 1995,22, 24-32

Identifying the characteristics of optimum

practice:findingsfroma survey of practice
experts in nursing, midwifery and health visiting
Tony Butterworth PhD MSc RGN RMN RNT DipN
Queens Nursmg Institute Professor of Community Nursmg, The University of
Manchester, Manchester

and Veronica Bishop PhD MPhil RGN

Nursmg Officer, NHSE and Professor of Nursing, Anglia Polytechnic University,
Chelmsford, Essex, England

Accepted for pubhcation 28 September 1994

BUTTERWORTH T & BISHOP V (1995) Journal of Advanced Nursing 22, 24-32

Identifying the characteristics of optimuin practice* findings from a survey of
practice experts in nursmg, midwifery and health visiting
In a questionnaire survey m England of 1221 practising nurses, midwives and
health visitors, 18 key characteristics of optimum practice, made up from 77
sub-Item categories, were identified by respondents Five open-ended questions
asked respondents to consider various aspects of optimum practice and to
comment on factors which encouraged those m practice to dehver care of the
highest quality Consensus of view was obtained through a Delphi approach
The researchers offer commentary on the implications of this research for
commissioners, providers and the professions and suggest action for those
concerned with the provision of health care

TNTTRnnTIPTTniVr ' ^ ^^ Umted Kingdom, clmical areas which demon-

strate positive characteristics have been designated as
The need for information to establish and maintain opti- nursing development units They have been supported by
mum practice in nursing, midwifery €ind health visiting is central funding initiatives and reported widely (Vaughan
of paramount importance in the development and main- 1992) There are also likely to be other centres where work
tenance of high quality care The reasons for this are many, of the highest quality from nurses, midwives and health
not least the 'flattened' professional management struc- visitors is to be found but will have gone unreported With
tures and the introduction of an internal market system increasing demeinds for attention to issues of quality and
which has forced renewed attention on the practice setting clinical leadership it is important to describe those matters
Captured m a series of policy target statements m the docu- which enable centres to carry out nursmg, midwifery and
ment A Vision for the Future (NHSME 1993), it is sug- health visiting which is of the highest standard Clearly,
gested that optimum practice is linked with matters of quality and
standards of care
professional leaders should be able to demonstrate the existence ~i , r , , > , . . , , .
, , r , , The interpretations ot quality identified by Attree
of networks for sharing good practice , „, , i , , , , , ,
(1993) are held to be central to this research In her review
and that of the literature Attree suggests that excellence, ldealness,
, , , . . . , , , , , , fitness for purpose and conforming to standards, meeting
providers should be able to demonstrate three areas where chnical , ,. , ,
, , , „ , the customers requirements, satisfying need and customer
practice has changed as a result of research findings , ii n 7 i r. , •, , . , . ^
value could all be identified, but she notes the lack of
Correspondence Professor T Buttenvorth, Tbe School of Nursmg Stud.es clarity and the Conceptual COnfusiOn whlch SUrrounds the
University of Manchester, Coupland 3 Building Oxford Road Manchester debate about Standards, lSSUes of quality Care and what
M13 9PL England could be defined as optimum practice

24 © 1995 Blackwell Science Ltd


The research
The research descnbed in this paper also has roots in per-
sonal attnbution (Kitson 1986) and matters of structure
(Taylor & Haussman 1991) It seeks to inform the pro-
fession further about those matters which are seen as
important by those in practice
The complex nature of nursmg, midwifery and health
visiting does not make description an easy task However,
there are research methods available which can provide
important insights This is an account of one such exercise
While the document A Vision for the Future (NHSME 1993)
set an agenda for the professions, and the subsequent docu-
ment Targeting Practice The Contribution of Nurses, Mid-
wives and Health Visitors (Department of Health 1993)
earned this forward by descnbmg examples of good prac-
tice, the research descnbed m this paper presents the views
of chmcally active and expert nurses, midwives and health
visitors on what constitutes and supports good practice
A I M S OF THE RESEARCH
The research was funded by the Department of Health,
England, and took place over a 12-month period
The agreed aims of the research project were
1 to provide intelligence on those matters which establish,
maintain and develop optimum practice m nursing,
nudwifery and health visiting, and
2 to gather information from, and generate correspon-
dence between, expert nurses, midwives and health
visitors
It was agreed that these questions should be addressed to
nurses, midwives and bealth visitors in practice
DEVELOPING THE METHODOLOGY
The task of generating discussion, achieving agreement
and consequently making policy decisions which can
claim to represent the view of a professional group,
IS methodologically difficult Delphi survey research
attempts to overcome some of these problems and was
selected as the method of choice for this exercise The April
July
Delphi research technique was developed as a method-
ological response to counter those problems identified m August
September
getting collective opinions from expert groups It is a way October
of eliciting and refinmg the opimons of a group of people November
who, in practice, are usually experts or knowledgeable January
individuals m tbe substantive area of interest
The advantages claimed (Linstone & Turoff 1975) for the
July
technique over other ways of elicitmg judgemental data
include its ability to reduce the tendency to 'follow the
leader' and its ability to lessen the bandwagon effect,
common m group settings It allows 'experts' who have no
history of communicating to do so It reduces, or ehmm- Figure 1 The timetable of research
© 1995 Blackwell Science Ltd, Journal of Advanced Nursing, Z2, 24-32
Charactenstics of optimum practice
ates completely, the possibility of a dominant personality
controlhng the outcome of the group, produces a threat-
free environment for an individual to state a personal opi-
mon and provides a communication stmcture m which
everyone has a chance to be heard equally
In common with all research methods, the Delphi
Techmque has limitations emd these (see Sackman 1975,
Goodman 1986) are acknowledged The method does not
claim to cover unexpected, spectacular and unanticipated
breakthroughs or to remove the uncertamty of the future
There are examples of this technique being used by earl-
ier researchers for the purpose of definmg matters related
to nursing and midwifery practice Farrell & Shearer (1983)
used the Delphi techmque to explore indicators of quality
nursing care Four major groups were selected to represent
the nursing population administrators, educators,
researchers and clinical nurses From this, nurses gave opi-
nions on what constituted quality nursing care Bond &
Bond (1982) used a Delphi research method to identify
clinical nursing research priorities In work for the English
National Board for Nursing, Midwifery and Health Visiting
(ENB 1993), researchers at the University of Manchester
used the method to determine views on educational
expenences with community nurses
There are examples where Delphi research has been
used to gather an informed view on likely developments
in psychiatnc nursing m the United Kingdom (White
1991), nursing m Europe (Butterworth 1991), nursing edu-
cation (Grotty 1993) and the role of front line managers
(Duffield 1993)
THE P R O G R A M M E OF RESEARCH
The research took the following fairly typical sequence of
seven steps The timetable is shown m Figure 1
1 A panel of methodology and practice experts was estab-
lished This group (group A) identified the key questions
to be asked and considered how to derive and then com-
municate with a panel of expert respondents (group B)
Establishment of the methods group |
1 Establishment of the expert respondent group
First questionnaire to expert group
1 Analysis of data from round 1
Second questionnaire to expert group
1 Analysis of data from round 2
Third communication to expert group
1
1 May 1 Final data analysis and presentation
of findings to Department of Health
25
 T Butterworth and V Bishop

2 The first round questionnaire was given to the expert from a group which, m the judgement of the nurse execu-
respondent group (group B) tives, consisted of practitioners whom they believed to be
3 Data from the first questionnaire were analysed and then both expert and offenng optimum care The selection was
considered by group A A second questionnaire was therefore subject to the biases and limitations that this
developed imposes The response rate from nurse executives reached
4 The second questionnaire was given to the expert 89% and they named 2006 nurses, midwives or health
respondent group (group B) visitors who fulfilled the necessary criteria and could be
5 Data from the second questionnaire were analysed and categorized as suitable respondents
then considered by group A No third questionnaire was
developed as a high meetsure of agreement had been
The nurses, midwives and health visitors as a
reached
'sample'
6 A third communication was sent to the expert respon-
dent group (group B) Nationai figures for nurses, midwives and health visitors
7 A draft report was produced m England have been supplied by the statistics and man-
agement division of the Department of Health m order that
the respondent group csm be seen m the context of work-
The expert methodology group (group A)
force figures (Table 1) This mformation has limited useful-
This group consisted of methodology and subject experts ness m that it mcludes some commimity nurses without
and was facilitated by the Department of Health Member- specific preparation and does not always discmmnate
ship of the group can be found at the end of this paper between level one and level two nurses Also, numbers of
school nurses sad practice nurses cannot be qusintified
easily from existmg DOH data sets
The expert respondent group (group B)
Nurses, midwives and health visitors identified for this
The methodology group debated ways of locatmg a group survey by provider authority nurse executives cannot be
of experts who could parbcipate in the research exercise seen m the context of these data, as the study asked for
Followmg investigation, three possible avenues for gather- particular characteristics m the respondent group
mg respondents were explored the live Register of the Nonetheless it is helpful to consider overall numbers m
United Kingdom Central Council for Nursing, Midwifery employment It is important to note that the expert respon-
and Health Visiting (UKCC), the Department of Health dent group cannot be considered as a representative strati-
(DOH), England, and the English Nationai Board for fied sample of nurses, midwives and health visitors m
Nursmg, Midwifery and Health Visiting (ENB) These pos- employment m England Equally they will not be a pro-
sibilities were rejected as their databases were either too portionate group nurrormg nationed figures The commonal-
difficult to sample, or focused on an inappropriate group ity that they share rests solely with criteria set out m the
of respondents questionnaire to nurse advisors m providing authonties
It was agreed that expert nurse, midwife and heedth visi-
tor respondents could be identified through nurse advisors
for each providing authority in England All regional nurse
Designing questions for the expert respondent
advisors m regional health authorities m England were
group
contacted by letter and the names of nurse executives for The expert methodology group considered construction of
all provider units were obtained Four hundred and forty- a first questionnaire A first version was locally piloted
one nurse executives were identified Each of these was and refined and a final version was sent to the identified
sent a letter and requested to supply the names of up to
five nurses, midwives or health visitors who Table 1 Whole time equivalent qualified staff in employment
1 had at least 5 years clinical experience and were cur-
rently m clinical practice, District nurses 19800
Health visitors 12 070
2 had a post withm the clmical grading structure of F, G,
Midwives 15660
or H or, exceptionally, were clinical specicJists at Community midwives
4200
grade I, and Community mental handicap nurses 1580
3 were nurses, midwives or health visitors whom the Mental handicap nurses 30150
nurse advisors could descnbe as skilled clinicians ofFer- Community psychiatnc nurses 3600
mg optimum care Mental illness 53170
Children's nurses 10 550
These criteria were established so that those involved Adult general nurses 161030
with clmical activity on a day-to-day basis would be at the Total 311810
heart of the study Inevitably, respondents were drawn

26 © 1995 Blackwell Science Ltd, Journal of Advanced Nursing, 22, 24-32

 Characteristics of optimum practice

expert respondent group The questionneure asked a senes

a? 60 -
of questions to establish the charactenstics of the res-

ondents
50 -
pondent group, followed by five open-ended questions

• •
Respondents were asked to give an opmion on each The 40 ^M 35
open-ended questions were
1 20 30 -

jmber of r
1 What IS It about your care that has led one of your 10
10
managers to consider you as someone who provides
- 05
1 ^H ^H ^^ 05
n
optimum/best practice' z U
E F G H 1 Other
2 How would you describe optimum/best practice'
Grade of respondents
3 What facilitates optimum/best practice m the place
where you work' Figure 2 Respondents by grade
4 If you were starting from the beginning and creating a
centre providing optimum/best nursing practice, what
ingredients would need to be present'
5 Are there any further comments you may have about 82
optimum/best practice'

The expert respondent group and their willingness

to participate
The 2006 nurses identified by nurse executives became
the expert respondent group and received the first ques-
tionnaire After a period of 3 weeks non-responders
received a remmder letter and a second copy of the ques-
tionnaire, 1221 members replied to the questionnaire
which meant a response rate of 61% This can be con-
sidered a respectable response rate for a questionnaire
survey but is lower than some other surveys A sample of
non-responders was contacted by telephone to try and
determine their reasons for non-completion It was van-
ously ascnbed to pressures of work and the considerable
changes being introduced by managers There were some
complaints of questionnaire fatigue produced by other sur-
veys and the constant demand for information
The project did not allow time to pursue another cohort
of respondents and a decision was made to proceed with
the group who had replied
ANALYSIS OF THE FIRST QUESTIONNAIRE
The charactenstics of expert respondents
Sixty-one per cent (1221) of the 2006 expert respondents
collaborated and answered two questionnaires Those
surveyed were predominantly between the ages of 31 and
45, 88% were women Although titles were many and
vaned, 82% were grades G & H and 82% had been m
active clmical practice for more than 10 years (see Figures
2 and 3)
The following practice settings were represented mid-
wives 13%, health visitors 10%, practice nurses 10%, dis-
tnct nurses 10%, commumfy psychiatric nurses 2%, and
charge nurses/ward sisters, ward managers, nurse special-
ists, CNS, semor nurses 50% (see Figure 4) Of these the
6-7 7-8 8-9
Years in practice
Figure 3 Respondents' years in practice
following qualifications were given (some multiple) RGN
87%, RMN 16%, RNMH 5%, and RSCN 8%
The respondent group represented a good spread of
interest, location and specialify They had substantial
clinical expenence and maturity and could be considered
as a suitable expert respondent group for the purposes of
this research
There was considerable confusion in respondents' job
titles (see Table 2) There appeared to be an lncreasmg
tendency for nurses, midwives and health visitors to be
descnbed by a range of confusing titles, having httle coher-
ent meaning to the profession and probably no meaning
at all to the public For example, ward manager, clmical
nurse manager, semor sister and ward sister may possibly
describe the same person but with subtle differences
There is little way of detecting these subtleties from this
research, and this possibilify of confusion is particularly
paradoxical m a profession grapplmg with the concept of
a named nurse
Defining categories for open-ended questions
1 Data from open-ended questions were analysed by a
small group of expert practitioners from the recently
constituted Practice Advisory Group (PAG) of the Chief
Nursmg Officer and Director of Nursmg, NHSE In an
intensive exercise they reviewed rephes from the expert

© 1995 Blackwell Science Ltd, Journal of Advanced Nursing, 22, 24-32 27

T. ButttTWOfth and V. Bishop

Practice nurses 10-0%

Health visitors 10-0%

Midwives 13-0%

CPN 2 0 %

Other 5-0%

CNS/CN/Sister50-0% District nurses 10-0%

Figure 4 The survey population by desigiiiitioii.

Table 2 Respondents by litle ({iwii University Department of Nursing, producing equally

acceptable inter-rater reliability scores.
Ward manager 115
Ward siHtc!!- 8H Tbis process inevitably demands that interpretation bo
CNS 120 placed on the wide range of answers provided by respon-
Health visitor 119 dents, but the process has as far as possible reached a
Nursii .specialiHt 21 genera! measure of agreement in categorization. A small
Senior sister 64 number of respondents fell outside these categories and
Sister 86 they represent an interesting and no less important point
Clinical nurse manager 44 of view; however, the process of Delphi research is
StaiY nurse 25
attempting to arrive at consensus and those matters which
Senior midwife 3'i
have general agreement are reported here. The few outly-
Senior nurse 30
'62
ing respondents who do not fit the general pattern can be
Midwife
36 separately identified and could be further scrutinized.
Charge nurse
Practice nurse 92 From the data it was possible to identify a list of 77
CPN 24 items. Tbese in turn could be gathered into 1.8 broader
Other (27 categories) 181 subject headings. The 18 broad subject headings became
known as the 'key characteristics' and are referred to as
such In tbis paper.

respondent group and created uategories for grouping

the data.
2 Questionnaires were scrutinized by the researcher and
answers c:oded within categories created hy stage one.
A small number of additional categories were created
where originals were found inappropriate.
3 The PAG subgroup was asked to rate blindly a number
of questionnaires, and inter-rater reliability tests were
applied using a modified Kappa test (Coben 1960). An
acceptable level of agreement was reached.
4 A similar test was carried out on data categorized
by both the researcher and subject experts from a
The 18 key characteristics and 77 suh-items of
optimum practice
Nurses midwives and health visitors providing
optimum practice
1. Are innovators. This was reported as: having the
ability to take on new ideas; being reflexive and reflective:
and being forwai'd thinking and innovative.
2. Demonstrate ieadarship. Tbis intrudes: being as.sert-
ive; having pride in one's work; being a role model of

28 © 1995 Blackweli Sinejice Ltd. Journal of Advanced Nursing, 22, 24-32


leadership, giving respect to colleagues, and bemg forward
thinking
3 Have key personal qualities Key personal qualities
included having a positive attitude, keepmg calm under
pressure, giving attention to detail, being approachable,
and givmg commitment
4 Can demonstrate positive communication skills This
was described as bemg able to give time, being skilled in
written eind verbal communication, bemg an available and
informed source for expert information, and having an
ability to commumcate effectively in a multi-disciplmary
team
5 Can demonstrate expertise This was defined as
having a broad experience which allows the demonstration
of expert practice, having competence, being up to date,
being a model of expert practice, and being able to teach
advanced practice skills to other nurses
6 Are able to work m a multi-disciplinary team This
was expressed through being able to share work with other
disciplines, articulating and making an equal effort to team
effort, having a clearly stated role, and being able to give
mutual respect to other colleagues
Requirements for optimum practice
7 A supportive environment for clinical activity and per-
sonal development This is achieved by having an active
model of clinical supervision, being able to give and
receive support, being able to give and receive criticism,
encouraging peer review, and providing mentorship for
new staff
8 Management which allows its development and gives
it support This IS expressed through management
which respects optimum practice and shows this through
active support, allows support to be returned from those
m practice, encourages involvement m decision making,
and allows practitioners to take responsibility
9 Active involvement with education This is achieved
by providing the opportunity to be a teaching resource
for students, active involvement with centres of edu-
cation, bemg a provider of ln-service education, and pro-
vidmg expenence for students undertaking clmical
experience
10 Active involvement m patient teaching/education
Active involvement was characterized by providing
knowledge to patients/clients, makmg opportumty for
health education and heedth promotion, bemg an expert
source of knowledge, and active involvement with teach-
mg patients and chents
© 1995 Blackwell Science Ltd, Journal of Advanced Nursing, 22, 24-32
Characteristics of optimum practice
11 That standards be set and issues of quality be
addressed This is shown through mvolvement with set-
ting standards, havmg and using protocols, being mvolved
with quality imtiatives, and being aware of the scope of
professional practice available to nurses
12 Political awareness This is obtamed through
knowledge of influential groups and mdividuals at a local
level and nationai level, and by bemg able to debate and
persuade withm a multi-disciplmary setting
13 A need to be aware of and involved m research
activity This requires access to appropriate library
materials, being able to use theory in practice, enabling
research in practice, and using research findmgs as a base
for, and to change, practice
Requirements for nurses, midwives and health
visitors to provide optimum practice
14 Suitable service support This is expressed through
reasonable clerical support, having an appropriately struc-
tured skill mix, and having weU-designed information sys-
tems that provide mtelligent and useable data
15 The right milieu This is achieved by creating an
atmosphere which is conducive to givmg nursing, mid-
wifery or health visitmg care and allows both carers and
pabents/clients a sense of ownership, having some control
over the throughput of patients/clients, and nurses, mid-
wives and health visitors pla3ning a part in devismg the
expectations of service delivery
16 Careful attention from the human support services
This IS effected through careful staff selection processes,
regular motivational support, frequent, well-run staff meet-
mgs, suitable staffing levels, and support from emd support
for managers
17 User involvement and client/patient ownership This
IS expressed through preserving patient/client dignity,
acting to sustain patient/client advocacy, giving open
access to service-specific mformation, encouraging con-
sumer feedback, and encouraging patient/client-held
records
18 To work withm a system of holistic care This
mvolves individualized patient/client care, care based on
a system of primary nursing, care which has well-
orgamzed discharge planmng, and contmmty of care
THE SECOND QUESTIONNAIRE AND
OBTAINING CONSENSUS
Followmg analysis of the first questionnaire, a second
questionnaire was developed and sent to the expert
29
 T Butterworth and V Bishop

respondent group in order to ascertam a measure of con- Recommendation for action

sensus on the defined charactenstics Expert respondents Target ten from the document A Vision for the Future
were presented with a questionnaire showmg the categor- (NHSME 1993) which refers to clmical supervision is
ies which had been developed and were asked to give each endorsed by this research, and mformation on clmical
a measure of agreement or disagreement by usmg a 5-pomt supervision should be extended by estabhshmg ongoing
Likert scale tnals of different models of chmcal supervision
Duffield (1993) reports on a Delphi study, givmg particu-
lar attention to the requirements for consensus This was I'm surpnsed that I've heen nominated as an expert, no one has
equally important m this study, which reached a strong hothered to tell me before
measure of agreement The data in this research demon-
strate that all categones were seen to have a measure of
agreement which fell mto either the 'totally agree' or
Being innovative
'agree' elements of the scale While this does not imply a Innovation requires that attention be given to the develop-
complete measure of consensus, most respondents were ment needs of staff providing optimum practice Number
able to agree with the categones m 29 cases and totally of years m practice is no guarantee of contmued excellence
agree in 48 These data indicate 'good enough' agreement and expertise There are cost implications which can be
and there seemed little point in attemptmg further agree- peirtly met by mdividual nurses but which also require
ment through a third questionnaire It was therefore tangible support from employers
decided that the third communication to respondents
would be an information giving exercise only Recommendations for action
1 Providers should attend to the development needs of
staff by ldentifymg a relevant programme of continuing
THE USEFULNESS OF THE KEY
education through individual performance review
CHARACTERISTICS: CONCLUSIONS AND
2 Commissioners need to identify a programme of
POINTS FOR ACTION
contmumg development of staff m their contracting
When the 18 key characteristics are considered m detail specifications
It becomes possible to see their value as ingredients which
might be built mto qualify controls Some are clearly
person- and possibly personalify-focused, and others have
Having expertise
to do with the culture of the clmical environment and how Respondents m this survey could claim a great depth of
It IS managed Some are therefore open to mfiuence eind expenence This expenence has as much vahdify m the
chemge and others less so The key characteristics are con- delivery of care as does the skill of the general manner
sidered further m the context of what they imply for the Health care dehvery requires a mutual respect which recog-
delivery of optimum health care On occasions they are mzes and values both orgamzational and clmical skills
taken together as the implications and issues are common Experts are ofien deferred to and referred to by other
In the following text there are some verbatim quotes from professions as the source of optimum practice It is evident
respondents which make tellmg observations from this research that the hard won status which clmical
excellence confers should be more openly acknowledged
Optimum nursing practice should be aimed at what the clients and fostered
need and want, not what we think they want A great deal needs
to be done to equalize the partnership between practitioners and Recommendations for action
clients so that optimum nursmg care can be given 1 The status of clinical excellence should be defended by
makmg sure that titles given to non-practitioners do not
suggest that they are climcally active
Giving support
2 Titles given to clmical staff should be unambiguous and
The power to provide support rests with provider man- clearly understood by patients/clients in particular
agers Although simple enough m concept it is seen by
some respondents to be vanable m qualify, and to require
renewed attention Clinical supervision has been rec- Communicating
ommended as a device which is necessary for the support Opportunities to communicate properly were deimaged by
and development of practice (Butterworth & Faugier 1992) pressure of work euid an mabilify of some managers to
In the document A Vision for the Future (NHSME 1993) see casework discussions as a legitimate part of work
climcal supervision is singled out for special attention Intelligent nursing, midwifery and health visitmg requires
and undoubtedly provides a vehicle for sustaimng and intelligent debate and management Optimum practice
developmg the profession requires skills m wntten and verbal presentation

30 © 1995 Blackwell Science Ltd, Journal of Advanced Nursing, 22, 24-32

 Characteristics of optimum practice

Recommendation for action often directed at short-term corporate requirements, to the

Opportunities for communication must be allowed to exclusion of personal development There should be
flourish Managers should identify tune to be made avail- opportunibes for both
able for proper communication Extremes of provision have been seen in this research
The report on a Strategy for Research m Nursing, Mid-
Personal qualities wifery and Health Visiting (Department of Health 1992)
provides good advice for research action, and the enthusi-
Key personal qualities are thought of as important for the asm for research-based practice shown by expert respon-
provision of optimum practice Their importance lies dents m this exercise finds support and expression in that
within the area of role modelling for students and other document
staff It IS clear from this study that personal qualities rate
highly with experts in practice Recommendations for action
1 Centres of climcal practice should be linked to databases
Recommendation for action and libranes in order to allow expert practiboners access
There should be further work to explore the importance to research-based information
of key personal qualities in the provision of optimum 2 Continumg education should not only be a matter of the
practice corporate need but should relate to individual develop-
ment Appraisal schemes can locate both corporate and
Patient care is only as good as the nurse who provides it Good
personal need and should be implemented at all levels
patient care comes from a nurse who is motivated, happy at work
and has good communication skills, has the relevant knowledge,
IS wilhng to question and change her practice as required The Working with people who use services
above nurse functions well under management with the same
motivation and skills with the foresight to empower staff This study has highlighted the importance of working
alliances between service users and nurses, midwives and
heedth visitors Where optimimi practice is provided there
Working with other professions IS often a workmg alliance between users and pro-
fessionals It IS necessary to go beyond the simple gestures
Multi-discipIinary work is offered by many as a key to the
which have often been given as evidence of user involve-
provision of effective care, and was clearly important to
ment It IS quite possible to empower users still further by
the expert respondents m this study Collaborative
mvolving them as equal partners m curriculum com-
working should be encouraged during first-level prep-
mittees, research design and quahty measures
aration, regardless of profession Experts m this study had
sufficient confidence to engage m an equal dialogue with
medical colleagues and could both take and give infor- Recommendation for action
mation and advice The combined product of a multi- The views and opinions of people who use services must
disciplmary team is a powerful one and this power rests be included m the provision of optimum practice by estab-
not only m its combmed force but also m defining healthy lishing a series of workshops and debates designed to
boundaries and professional responsibilities encourage a new partnership between user groups and
nurses, midwives and heedth visitors
Recommendation for action
I don't bog down my manager with tnvia, but I do talk to her and
Imtial and continumg education should include oppor-
mvolve her m my cases if appropnate
tunities for multi-disciplmary study This should be ident-
ified when purchasing education
Being well managed
Practice is facihtated in the place where I work by a nurse edu-
cation centre that is interested m nursmg care m the chnical areas Simple matters were reported as frustratmgly absent and
easily rectifiable It was clear that some individu£tls were
struggling without clencal support and were often usmg
Sustaining and developing expertise
unintelligible and hopeless information systems There is
hi order to maintain optimum practice there must be evidence that the peutnership between managers and
access to hbrary materials and resources Equally, although experts m this study is central to the provision of opti-
I experts have displayed a great wiUmgness to attend to mum practice
their own ongoing educational development, employers Support from some managers was not always evident
carry some responsibility There is clear evidence of dim- and simple gestures of praise or encouragement were not
mushing opportunities for attending courses and study given to balance the demands for change Staff meetings
days More particularly, such help as there is available is were sometimes badly run, without agendas or discussion.

© 1995 Blackwell Science Ltd, Joumal of Advanced Nursmg, 22, 24-32 31

 T Batterworth and V Bishop
and human support services were seen by some as
unskilled m selectmg new staff
Interestmgly, experts recogmzed the pressures upon
managers and on occasions wanted to give recogmtion and
support where it was due This was not always possible
because managers did not make themselves available to
receive it
Recommendation for action
There should be a clear statement to purchasers which
describes and demonstrates the active mvolvement of the
human support services in the climcal arena emd the
nature of motivational support available for climcal staff
I have a wonderfully supportive senior nurse and general manager
who have enabled me to do all this work They have been there
when and if I need them — but not breathing down my neck
The Expert Methodology Group
Professor Veronica Bishop, Department of Health,
England Dr Senga Bond, Umversity of Newcastle,
England Professor Chnstopher Maggs, Umversity of
Wales, College of Medicme, Wales Dr Donna Mead,
Umversity of Swansea, Wales Dr Sue Armitage (now
Professor of Nursmg, Umversity of Sydney, Australia) Ms
Barbara Vaughan, Kmg's Fund Centre, London, England
Disclaimer
The views expressed m this paper are those of the authors
and do not claim to represent the funding agency — The
Department of Health, England
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