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Practice Development Credentialing in the United Kingdom – A Unique Framework for Providing Excellence, Accountability and Quality in Nursing and Healthcare

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Helen Chin, MSc, RN
Elaine Mc Nichol, MSc, BSc (Hons.), PG Dip., RMN, RNT

Abstract

This paper will describe the purpose, process and value of an international Practice Development Program by which clinical units can choose to be credentialed. It will describe how the fourteen criteria that a Unit is credentialed against takes them along a journey of practice, personal and professional development that equips them to not only positively respond to, but to proactively influence, the challenges and changes that healthcare is facing globally. It explains how The Program focuses on credentialing sustainable practice development that then contributes to the development of both the capability and capacity of healthcare services. As a result, it crosses professional and organisational boundaries and constraints and concentrates on their shared purpose, delivering excellent patient care.

Citation: Chin, H., Mc Nichol, E. (May 31, 2000). "Practice Development Credentialing in the United Kingdom – A Unique Framework for Providing Excellence, Accountability and Quality in Nursing and Healthcare". Online Journal of Issues in Nursing. Vol. 5, No. 2, Manuscript 4. Available www.nursingworld.org/MainMenuCategories/ANAMarketplace/ANAPeriodicals/OJIN/TableofContents/Volume52000/No2May00/CredentialinginUK.aspx

Key words: Practice Development, Organisational Development, Credentialing, Clinical, Practice, Education

Introduction

Healthcare is changing at a breathtaking pace and has recently been described as being in the midst of a social and technological transition (Porter O’Grady & Krueger-Wilson 1995). Led by innovations in science, technology and communications, society is transforming itself and its expectations to ever-higher levels of sophistication, excellence and a desire for involvement and ownership in public services. Fuelled by these developments, healthcare has not been able to escape this transformation. New demands are being placed upon healthcare systems, and its modes and delivery of care.

Governments therefore find themselves under increasing pressure to provide collaborative, comprehensive evidence-based quality care within finite resources to meet these demands. As a result, new policy agendas focus upon clinical and cost-effectiveness, shared governance, equity, and accountability through the use of evidence-based care and proven quality outcomes (Department of Health, United Kingdom, 1997).

Responding to these policy agendas constitutes a complex and formidable task particularly for providers of healthcare. To keep up with emerging trends and to cope with constant change and complexity, new ideas and fresh ways of approaching the practice and organisation of healthcare are required. To succeed, the process and practice of healthcare needs to transform itself to involve all stakeholders and systems. Systems need to become pro-active, synergistic, entrepreneurial, dynamic, rewarded and sustainable (Centre for the Development of Nursing Policy and Practice (CDNPP) 1999). Credentialing of units within healthcare organisations which evidence such qualities may be one way forward in meeting contemporary healthcare agendas and developments in the 21st Century. This paper will describe the history of practice development credentialing, the process of practice development credentialing and evaluation and outcome measures used in credentialing.

History of Practice Development Credentialing

The concept of practice development was pioneered in the United Kingdom by Pearson (1983) who developed nurse led initiatives at Burford Community Hospital, Oxfordshire. Within this unit nurses became responsible for the admission, care management and discharge of patients, using their discretion to call upon doctors when necessary (Hamer & Totterdell 1999). In 1989 Wright took the concept further and emphasised team building and staff development as an integral part of practice development. These initiatives set a precedent within nursing and healthcare, and with it a realisation that nurses were not only well placed to lead initiatives but were competent to do so. It supported the notion that change must begin with the largest group closest to the point of service. If change can happen here, it is deemed to be able to happen anywhere in the system (Porter O’Grady & Krueger-Wilson, 1995).


The policy goal has become to incorporate these diverse groups to address a wider remit which emphasises a collective responsibility for the quality of patient care, and encourage the sharing of best practice.

In subsequent years the concept evolved organically to include the multi-disciplinary team, cross boundary agencies and service users. Contemporary practice development units now consider the interconnectedness and inter-dependency of health/social care systems and stakeholders. They take into account the complexity and restrictions imposed by fiscally controlled organisations. The policy goal has become to incorporate these diverse groups to address a wider remit which emphasises a collective responsibility for the quality of patient care, and encourage the sharing of best practice (Department of Health, 1997). Credentialing has thus come to focus on the broader elements of healthcare strategy, practice and policy development (CDNPP 1999).

 

Practice Development Credentialing – A Way Forward

Practice development credentialing has been described as a method of external peer review of an organisation using explicit standards (Scrivens, 1995). The process of credentialing recognises practice development as a journey of discovery and development. It is currently being led in the United Kingdom by the Centre for the Development of Nursing Policy and Practice at the University of Leeds, Leeds, United Kingdom. This program has been acknowledged as a mechanism by which leading-edge practice, innovation and creativity can flourish within an empowered and motivated workforce (Gerrish, 1999).


The framework of the Practice Development Credentialing Program offered by the Centre is provided in the form of 14 criteria.

The framework of the Practice Development Credentialing Program offered by the Centre is provided in the form of 14 criteria. To become fully credentialed all of the criteria must be met in full. They must be evidenced in practice and in the form of written submission documents. Support and assessment is co-ordinated by the Centre, which promotes a matrix of learning and development opportunities. A four strong team, all of whom are experienced in the nature, complexities and processes of Health and Social Care development, run the day-to-day elements of the program and provide on-going support, consultancy, co-ordination and communication to the Units. Complementing their efforts is a panel of twenty-two experts who make the final decision to credential Units following on-site visits and are responsible for program monitoring and evaluation. Collectively they have wide experience in areas such as:

  • Organisational development at executive levels
  • Change management at clinical, strategic and policy levels
  • Business administration
  • Research and tertiary education
  • Clinical practice – multi-agency and disciplinary
  • Project and process planning and management
  • International health and social care development
  • Financial and human resource management
  • Policy analysis
  • Needs assessment
  • Quality assurance, standard setting and risk management


Overall, the program is designed to be a journey of discovery and development which enables an organisation to ride the waves of change in healthcare policy and reach their expected goals through innovation, creativity and leading edge practice within existing resources.

The criteria set out by the Centre have been developed with an aim of providing a vehicle for promoting best practice and disseminating innovation (CDNPP, 1999). This primary aim is interdependent with a secondary aim of developing practitioners, both personally and professionally (Gerrish, 1999). Overall, the program is designed to be a journey of discovery and development which enables an organisation to ride the waves of change in healthcare policy and reach their expected goals through innovation, creativity and leading-edge practice within existing resources (CDNPP, 1996). Guided by national policy frameworks, organisational support and commitment at executive level, and baseline situational analyses, the approach to practice development is systematic, rigorous and boundaried. A brief description of the credentialing criteria are presented in Figure 1. These criteria place a strong emphasis on staff and client empowerment, shared leadership and de-centralised decision making.

Credentialing is a process of formal, external validation by The University of Leeds of the quality of professional practice and clinical care demonstrated within a particular Unit. Each Unit is unique and differs in size and composition. They range from a small uni-disciplinary team to a whole clinical directorate encompassing a number of clinical areas and a range of professions that may number over a hundred people in total. The unifying characteristic of all Units are that they are a defined clinical area; and that the staff working within that area have both chosen and can influence the credentialing process.

Credentialing itself does not bring any formal privileges in regards to extra resources or favoured treatment by the organisation. To do otherwise, would compromise their ability to fulfil the criteria which states that practice development must occur within baseline resources to support the transferability of practice. However, credentialing does positively impact upon a Unit, ‘opening doors’ and creating opportunities.


However, the experience of the Practice Development journey increases staff skills and their awareness of opportunities and therefore their ability to apply for research and practice development resources.

However, the experience of the Practice Development journey increases staff skills and their awareness of opportunities and therefore their ability to apply for research and practice development resources. The University kite mark brings a credibility that enhances a Unit’s chance in being successful in such bids. Individually, being a member of a Unit that has been credentialed enhances a person’s employability as it a positive statement about their attitude and approach to work. This is evidenced by the fact that unlike most areas of healthcare in Britain, credentialed Units rarely have a problem with recruitment and retention. All credentialed Units receive a wall plaque formally stating their achievement to inform the public using their services that they have voluntarily subjected themselves to external scrutiny and been identified as an area of practice excellence.

It is important to recognise that credentialing is a voluntary process that a Unit chooses, it is not a requirement of the United Kingdom’s healthcare service. This independence from statutory requirements is important as it has enabled the Program's philosophy, values and the fourteen criteria to be transferable to a wide range of healthcare and cultural settings beyond both the United Kingdom and its National Health Service.

Creating a Conducive Environment to Enable Innovative Practice Development

For those embarking on the process of credentialing there is a general consensus that, in order to develop a patient oriented quality service, achieve optimum practice and disseminate their innovations, staff must first be enabled to reach their full potential and function effectively together as an intra -disciplinary, self-directed team (Gerrish, 1999).

In order for the staff to reach their full potential and become self-directed teams, the organisation takes on a degree of responsibility and risk and is encouraged to demonstrate support by devolving a significant amount of control in decision-making, planning and problem solving to both staff and clients. To this end, the credentialing criteria encourage a contemporary decentralised approach to management and leadership practices where responsibility, authority and accountability are locally owned through articulated expectations at all levels of the organisation (Creative Healthcare Management [CHCM], 1998). The goal is to encourage an empowered learning organisation which continually expands people’s capacity to create the results they desire, nurtures new patterns of thinking, establishes collaboration and espouses a culture of ‘learning to learn’ together (Senge, 1990).

At the Unit level the team and clients reciprocate their responsibility to the organisation. This is achieved by demonstrating a high degree of integrity and accountability to devolved responsibility and authority. Within the Unit, accountability is evidenced by a retrospective, concurrent and pro-active commitment to continuous growth and development, decision review and outcome evaluation (Manthey & Miller, 1994). Such growth and development occurs in the domains of critical thinking, technical skills and interpersonal relationships (Del Bueno, Griffin, Burke, & Foley, 1990).

Meeting the Criteria

The fourteen criteria set the framework to develop processes required to achieve credentialing and are designed to be flexible enough to consider the uniqueness of each individual Practice Development Unit. No two Units are the same and each one will experience different journeys of learning and development relative to their individual needs.


As the primary aim of the Practice Development Program is to achieve quality patient care through determining best practice, it is only achievable if the intra-disciplinary team is functioning effectively from the start and the unit has effective leadership.

As the primary aim of the Practice Development Program is to achieve quality patient care through determining best practice, it is only achievable if the unit team is functioning effectively from the start and the unit has effective leadership. Baseline assessment may facilitate this process and can be re-administered at regular intervals to determine whether there have been any improvements. Units generally adopt a mixture of quantitative and qualitative approaches that include audits, questionnaires and semi-structured interviews. The areas assessed usually include specific clinical practices in the form of clinical pathways and outcomes, compliance with professional standard requirements and patient and staff satisfaction. As with any change, it is presumptuous to assume that any one factor is singularly responsible. However, a recent evaluation of the Program (Gerrish, 1999) does suggest that in the process of developing the intra-disciplinary team as a priority, Units do report a significant improvement in achieving quality care.

As a guiding principle, Units are firstly encouraged to embrace a culture that espouses life-long collaborative learning where each member of the unit’s team must be actively involved in personal and professional development planning (Criteria 1 & 2 Figure 1). Many units will take an extra step towards this goal, which initially entails a determination of their collective values from whence a shared culture and philosophy may emerge. Tools such as team functioning or culture questionnaires such as the Team Index 360 (Index 360 Ltd., 1993) may be administered to establish a baseline measure. To complement the Unit's own efforts and support Unit leaders, the Centre offers an inclusive 3 day Kick-start Program which includes a 360 degree Leadership Effectiveness Analysis (Management Research Group, 1998) providing participants with a detailed analysis of their role related leadership behaviours. By utilising complementary approaches, both Unit Leaders and their teams are then provided with a fair assessment of their individual and collective developmental needs and are able to plan and action team-building and learning strategies, which will help them to live their common culture; for example a culture that among other things promotes growth and development, and achieve a shared vision. This is often then maintained, in part, through facilitated ‘time out’ days in which Units re-visit their shared vision and values and through the facilitator, both review and explore whether they are continuing to grow and develop in a cohesive manner. In addition, some Units, either alone or through their host organisations participate in a licensed three day development program called "Leading an Empowered Organsiation" (CHCM, 1998) which has a strong emphasis on relationship management and team culture.

To promote the culture of growth and development the credentialing process is also supported by the involvement of tertiary education. The goal here is to formulate theory, develop clinical practice and staff as appropriate and to develop a research-based approach to practice which incorporates: a spirit of inquiry; the critique and application of research findings; and a significant participation in individual and collaborative research (Criteria 6 & 7). Through their innovations and determination of best practice, Units are expected to reciprocate in the relationship with tertiary education and feed their developments into post-graduate programs and act as change agents by disseminating evaluated practice at local, national and international levels (criteria 6,7 & 9).


Once Units are fully credentialed they are invited by The Centre to develop theory and policy at an advanced, politically active level by joining the Practice Development Alliance.

Once Units are fully credentialed they are invited by The Centre to develop theory and policy at an advanced, politically active level by joining the Practice Development Alliance. The Alliance is a vehicle, which acts as an action learning set and think-tank and has been developed by the Centre to facilitate credentialed Units in proactively influencing and guiding local, regional and national policy from a practice perspective. This might be in relation to healthcare developments in general or to a specific specialist area of practice such as rehabilitation, palliative or mental health care. The Alliance is open to all disciplines, the only defining membership criteria being that members are a clinical leader of a credentialed Unit within The Centre’s Practice Development Program.

In addition to addressing developments at the micro level, Units are also required to submit a detailed business plan, which considers the impact of practice development at the macro level of resource implications, strategy and policy. The business plan is a key strategic document that identifies the objectives for development, targets for achievement and includes an evaluation and dissemination plan. It provides the Unit with a clear focus and direction to practice development and facilitates a systematic, resourceful and boundaried approach, which should be linked with local and national policy initiatives. Formed from the input of all stakeholders, this document acts as a collaborative statement of intent and action planning in which developments are shown to be realistic, transferable, sustainable and achievable within existing resources e.g. time, expertise and finance (criteria 3,4 & 8).

Evaluation and Outcome Measures

The criteria not only provide a framework for systematic practice development, they also provoke a robust approach to the issue of evaluation and the measurement of quality clinical outcomes. In keeping with the principle of facilitating Units to develop a ‘spirit of inquiry’ approach to their work, the Credentialing Program is not prescriptive as to the nature and type of tools that Units should be implementing. Instead, it is considered to be an important part of the developmental process for Units to research and identify their own evaluation measures. In this way, they can utilise tools appropriate to their clinical environment, which provide them with the type of data and feedback they are looking for. It is important that the measurement tools Units choose to implement have the capacity to reflect the richness and diversity of care that is being practised within their specific clinical areas. In general the Units focus upon two areas: clinical outcomes and service user satisfaction.

Clinical Outcomes


As a result, Practice Development Units look to implement a wide range of outcome measures, which travel the quantitative-qualitative spectrum and which may measure certain aspects of care.

Due to the holistic nature of multi-disciplinary care, it is inappropriate to measure its impact in purely linear quantifiable terms. As a result, Practice Development Units look to implement a wide range of outcome measures, which travel the quantitative-qualitative spectrum and which may measure certain aspects of care. These include clinical specific tools such as the Palliative Care Outcome Scale (Hearn & Higginson, 1999), to a more generic instrument such as the Newcastle Satisfaction with Nursing Scale (Thomas, Mc Coll, Priest, Bond, Boys, 1996) which assesses the quality of nursing care being provided. The intra-disciplinary nature of a Practice Development Unit espouses an overarching culture and commitment to the concept and practice of clinical audit and quality assurance. This enables a partnership approach to measuring the efficacy of clinical care and promotes review of practice in light of the findings, a process which is currently being strengthened through a national commitment to clinical governance.

Service User Satisfaction

Often evaluated through more locally determined methods, including tools designed by the organisation or local non-statutory agencies and charities, approaches usually range from survey questionnaires, to one on one interviews to focus groups. Combinations of these data gathering methods can be used and Practice Development Units are required to understand the fundamental research principles of validity and reliability in regard to sampling methodology and data collection, to ensure that the data collected is of sufficient quality to withstand analysis and subsequent critique.

Evaluating the Program's Overall Effectiveness in Improving Patient Care

Whilst the need to measure the Unit’s effectiveness in improving patient care is acknowledged, there is a difficulty in trying to attribute a change in the well-being of clients solely as a result of adopting the Credentialing approach (Gerrish, 1999). Many other variables may contribute to quality and effectiveness, although measurement compared to baseline evaluation, made prior to embarking on the journey, may provide some indications as to improvements.


The success here was in the Unit’s ability to build upon existing capacity by finding ways of providing ‘more’ within the finite resources available to them.

However this may be, a recent independent evaluation of the Credentialing Program commissioned by the Centre (Gerrish, 1999) noted that the Program framework appeared successful to Credentialed Units. The success here was in the Unit’s ability to build upon existing capacity by finding ways of providing ‘more’ within the finite resources available to them. Innovations in practice have come through the development of a synergistic team, application of critical thinking and entrepreneurship, the use of research utilisation and audit, the practice of integrating existing services and the creative use of skill mix. Most organisations that have adopted the Credentialing approach felt that these developments were congruent with the current national policy drive for clinical governance and cost effectiveness. All agreed that Unit Credentialing had made a significant and valuable contribution not only to the national agenda, but also to the morale, motivation and retention of their staff. The general consensus from organisations is that the process of credentialing offers clear benefits to clients, staff and the wider healthcare environment.

Conclusion

It is clear that healthcare practitioners who are at the point of delivery are well placed to implement changes in their practice leading to excellence and quality in healthcare (Porter-O’Grady & Krueger-Wilson, 1995). Supported by an empowered, decentralised and accountable culture, innovations in practice are enabled, quality is assured and opportunities arise in the realms of policy and theory generation within clinical practice. The process through which this happens is evolutionary and quite sophisticated. Therefore, adopting empowered and decentralised approaches to management and leadership within healthcare is not a straightforward matter. It requires collaborative commitment at all levels within an organisation and is a culture that needs time to be understood, to become mature and thus to be lived. Self-directed, intra-disciplinary teams develop over time and must be allowed to move along a developmental continuum from unit based groups to inter-departmental co-operation, to collaborative practice and then to self-direction (Katzenbach & Smith, 1992). Every stage of the process is dependent upon the degree of autonomy granted and the degree of development attained; so for any team to be successful, it needs to be built on a clear vision and a structure that supports forward movement (Creative Healthcare Management, 1998).

Although compliance to national accountability frameworks directs quality issues to some extent, the process leading to credentialing is voluntary. The Practice Development Program provides a comprehensive framework, which facilitates innovation, leadership, creativity and leading edge practice within existing resources. It helps Units to achieve their goals and meet with national agendas by choice, rather than being enforced and owned by the establishment (Hamer & Totterdell, 1999). In short, developing practitioners enables them to develop professional practice to benefit client care, which in turn enables them to develop professional knowledge and impact upon policy (Gerrish, 1999).

Authors

Helen Chin MSc., RN
E-mail : l.j.yates@leeds.ac.uk.

Helen is an experienced and award winning healthcare professional and program manager, most recently specialising in palliative care initiatives at senior level in an international context. She possesses a particular interest and consultant level experience in sustainable practice healthcare development through effective leadership, management, collaboration, research and education. Helen has worked extensively in Malaysia where she was responsible for the implementation of a community based palliative care service. She is currently working as an associate for the Centre for the Development of Nursing Policy and Practice, University of Leeds, where she is co-managing the Practice Development Program and delivering other leadership programs.

Elaine Mc Nichol MSc, BSc (Hons.) PG. Dip., RMN, RNT.
E-mail : e.mcnichol@btinternet.com

Elaine is an experienced healthcare professional whose clinical speciality is in the field of mental health nursing. Whilst working in the area of substance misuse, she gained ‘hands on’ experience of the Practice Development Program as clinical leader of one of the early Units to be credentialed. She then moved on to work as an advisor on clinical and professional nursing issues in a large Community and Mental Health Trust, but continued her links with the Program as a member of the credentialing team. During the last two years, Elaine has been working as an Independent Consultant with her own professional portfolio specialising in practice development through the delivery of a range of leadership and creative thinking programs. She is also an associate of The Centre and co-manages The Practice Development Program

References

The Centre for the Development of Nursing Policy and Practice (1999) The Practice Development Credentialing Scheme – A Program from the Centre for the Development of Nursing Policy and Practice. School of Healthcare Studies, University of Leeds, Leeds, U.K.

The Centre for the Development of Nursing Policy and Practice (1996) Nursing/Practice Development Unit Accreditation Scheme. School of Healthcare Studies, University of Leeds, Leeds, U.K.

Creative Healthcare Management (1998) Leading an Empowered Organisation. Creative Healthcare Management- a Division of CNM, Inc. Minneapolis, MN. USA.

Del Bueno D, Griffin LR, Burke S.M., Foley M.A. (1990) The Clinical Teacher: A Critical Link in Competence Development. Journal of Nursing and Staff Development. 6, 135-138.

Department of Health (1997) The New NHS (National Health Service) : Modern and Dependable. Her Majesty’s Stationery Office, London, U.K.

Gerrish K (1999) Practice Development : Criteria for Success – An Evaluation of the Practice Development Programme offered by the Centre for the Development of Nursing Policy and Practice at the University of Leeds. Centre for the Development of Nursing Policy and Practice, School of Healthcare Studies, University of Leeds, Leeds, U.K.

Hamer S & Totterdell B (1999). Unit Linked Excellence. Nursing Times Nursing Homes. November-December Vol 1, (4) 20-21.

Hearn J & Higginson I (1999) Development and Validation of a Core Outcome Measure for Palliative Care: The Palliative Care Outcome Scale. Quality in Healthcare. 8 : 219- 227

Index 360 Ltd. (1993) Team Index 360. Meadowside, Skeffington, Leicestershire, England. U.K.

Katzenbach J & Smith D. (1992) The Wisdom of Teams : Creating High Performance Teams Harper, New York.

Management Research Group (1998) Leadership Effectiveness Analysis. Management Research Group, Munchen, Germany.

Manthey M & Miller D (1994) Empowerment through Levels of Authority. Journal of Nursing Adminisatration. 24: (7-8): 23

Pearson A (1983) The Clinical Nursing Unit. London, Heinman

Porter-O’Grady T & Kruegar-Wilson K (1995) The Leadership Revolution in Healthcare : altering systems, changing behaviours. Aspen, USA.

Senge P (1990) The Fifth Discipline: The Art and Practice of Learning Organisations. Doubleday, New York.

Scrivens E (1995) Accreditation: The Way Forward for the National Health Service? Keele University, Keele University Press, Keele, U.K.

Thomas L , Mc Coll E, Priest J, Bond S, & Boys R. (1996) Newcastle Satisfaction with Nursing Scales: An Instrument for Quality Assessments of Nursing Care. Quality in Healthcare. 5: 67-72.

Wright S (1989) Defining the Nursing Development Unit. Nursing Standard 4 (7), 29-31.

Criteria for Credentialing

  • The Unit embraces a culture of decentralised decision-making, and staff and client empowerment.
  • Each member of the team is actively involved in personal and professional development, which is clearly identified in a personal development plan.
  • The business plan includes the process for disseminating evaluated practices both within the organisation and externally; reflects development processes within organisational strategies, local and national policies; identifies the resource requirements needed to achieve credentialing in terms of time, expertise and financial support; addresses the issue of succession planning.
  • The Unit operates within baseline resources comparable to other clinical care settings within the organisation to enable transferability of developments
  • Developments within the Unit are evaluated and reviewed in terms of their impact upon the client, organisation and staff
  • A research based approach to practice is developed which incorporates; a spirit of inquiry; the critique and application of research findings; a greater participation in individual and collaborative research
  • There is evidence to support close collaboration with tertiary education to formulate theory and develop clinical practice and staff as appropriate
  • The multi-disciplinary team and related external agencies are fully involved to ensure that resources are managed efficiently and effectively
  • The Unit acts as a change agent within the organisation, the region, nationally and internationally, publicising its success to promote the value of best practice
  • The team demonstrate ownership and accountability of the credentialing approach
  • The team view this concept of change as a positive experience
  • The Unit is identified as a defined area or team, such as a ward, clinic, community team, clinical directorate or primary/public health group
  • A Practice Development Unit Leader(s) is identified who will lead the team in the developments, evaluation and dissemination of their work and will have authority for practice within the Unit.
  • A steering group which must include a Clinical leader, the Chief Executive/Senior Organisational Board Member, Chief Nurse Executive, a senior member representing partnerships and / or related agencies within the organisation and a representative link from a university. The group must adequately reflect the professional and client group of the Practice Development Unit and include the clients’ voluntary / social perspective.
Copyright – Centre for the Development of Nursing Policy and Practice, School of Healthcare Studies, Baines Wing, University of Leeds, Leeds, LS2 9UT U.K. 1996.


© 2000 Online Journal of Issues in Nursing
Article published May 31, 2000


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