Compassion in facilitating the development of person-centred health care practice
© van Lieshout et al. 2015
Received: 17 September 2014
Accepted: 27 May 2015
Published: 6 June 2015
Person-centred practice, which includes compassion, needs to be well facilitated in order to flourish in healthcare settings. Facilitation is known to be complex and requires expert knowing and skills. The importance of adequate facilitator support is recognised. The literature however is unclear about the nature of this support and how it can be offered to facilitators while engaging with others in real world practice contexts.
This paper presents a lived experience of a doctoral student working as a facilitator with clinical nurses and their leaders, to develop person-centred health care practice, through action research. Compassion with others and self is apparent throughout the experience. It illustrates a facilitator’s felt need to respond to this emotion that is triggered in the engagement with others, but which often is hindered by the context and perceptions of the situation. This causes imbalance within the facilitator, which in turn challenges the achievement of synchronous working with practitioners and the development of person-centred practice.
A strong interplay between contextual and facilitator characteristics in the relationship with others impacts on the development of person-centredness in practice. Therefore compassion, as one of the attributes of person-centred practice, is fragile and fluid when lived in facilitative practice. A compassionate system of support is suggested to enable an understanding of context and self, in order to become and remain a person-centred, compassionate, facilitator in dynamic health care contexts.
A compassionate system of support has the potential to help professionals to navigate the context, without losing oneself, in the process of enabling person-centred, compassionate practice to thrive. Such support suggest an ‘ethic of care’ for the facilitator in discovering and engaging with the emotional context of facilitating person-centred practice.
Worldwide, there is an increase in initiatives undertaken in healthcare, in which the human dimension of caring gains explicit attention. The development of person-centred care and compassionate care practices are illustrative of this increase [1–5]. These initiatives are responses to various societal and political changes and challenges that health care is currently facing, such as, an aging population, economic down-turn, public engagement in health and social care services, self-management, reliance and the development of services that are tailored to individual needs . This requires role changes for professionals, in which the ‘person’ rather than the patient is placed at the centre of care . As a result, the professional domain is strengthened and there is a greater emphasis on compassion in care, instead of a more dominant focus on business delivery targets .
Person-centred practice and compassion
Person-centred nursing was developed by McCormack & McCance [9, 10] by building on the work of Carl Rogers  amongst others. It is an approach to practice that focuses on how health care providers relate to people in need of care, others significant to the lives of these people and colleagues and other care providers. Person-centredness reflects the concept of ‘caring’ and is underpinned by values of mutual respect, understanding for persons and individual rights to self-determination. Drawing on the framework developed by McCormack & McCance [9, 10], care is delivered through a range of activities, including, working with patient’s beliefs and values, engagement, having sympathetic presence, sharing decision making and providing holistic care. The expected outcomes are satisfaction with, and involvement in, care, feeling of well-being and creating a therapeutic environment.
Compassion is an interpersonal phenomenon which is defined by Chochinov  as ‘a deep awareness of the suffering of another coupled with the wish to relieve it’ (p.186). Like person-centredness, it is also a relational, caring activity for other human beings when they are vulnerable. It involves experiencing an emotional reaction when noticing someone suffering, which stimulates meaningful action in the relationship . In person-centred practice the other does not necessarily need to be vulnerable or suffering, rather it is the relationship with the other that triggers a felt need to help. Nevertheless, vulnerability in the therapeutic relationship may occur and thus compassion can be perceived as characteristic to person-centred practice.
Person-centred practice emphasises the importance of a supportive care environment and specific prerequisites of the professional, such as, intra–and interpersonal skills, in order to achieve person-centred and compassionate relationships in care practices. Although there is much knowledge on what characterises these practices and what processes and activities are supportive to the development of these relationships, less is known about how these practices, processes and activities are implemented in practice and the dynamic and challenges that brings.
Facilitating person-centred practice
It is suggested that care providers require appropriate support, facilitation and strong leadership, if person-centred practices and compassion are to flourish [2, 10]. According to Kitwood , ‘active learning’ and ‘facilitation’ are assumed to be key for the development of caring cultures within health care that are underpinned by a particular view of persons and personhood. Facilitation is a helping relationship, in which reflexive activities take place that are concerned with the development of individuals and groups. The goal is to help foster greater initiative, self-reliance, and motivation . Facilitation can be offered by someone in a formal, facilitator role, but it can also be embedded in any role, e.g., researcher, clinical team leader, practice developer or a health care professional.
Facilitating transformational processes within the development of person-centred care practices is considered challenging and as requiring expert knowing and skills [10, 16]. This expertise is necessary to overcome the challenges of working within healthcare settings that always have multiple sub-cultures, complexities and dynamics. It is well-known that contextual and professional issues frequently impact on the effectiveness of facilitators as they sometimes struggle to contribute to change. Facilitators need flexible means and a praxis1 approach to challenging situations that keep evolving and that do not lend themselves to straightforward technical explanations and solutions. Whilst a facilitator uses multiple knowing, tools and energy to support others in developing their practice, there is a risk that they themselves are left without support. The importance of adequate facilitator support is recognised. However, the literature is unclear about what this should entail and how facilitators can be supported during their engagement with others in real world practice contexts.
As person-centredness is also recognised as an enabling factor in the development of more humanistic practices, it is vital for the facilitator to know and act as a person-centred facilitator. This means, to live the principles underlying person-centredness in their facilitation and to role model person-centred relationships. ‘Being’ a person-centred facilitator in current dynamic health care contexts however, is complex and can evoke all kind of imbalances, as shown in the doctoral study by Famke van Lieshout , the first author of this paper.
This article reveals the challenges of being a person-centred facilitator (which includes being compassionate) by presenting Famke’s real world experience of first-time facilitation of emancipatory/transformative practice. Her account builds on data systematically gathered in the orientation phase of her participatory action research (PAR) study. The insights shared here are the result of her analysis and interpretation of these data in a subsequent hermeneutic study. The aim of presenting these insights is to help health care professionals identify with this experience and consider the potential value of the suggested action. This action is concerned with finding ones-self a system of support in becoming and remaining person-centred and compassionate, while engaging with others in the development of person-centred practice within complex, dynamic and sometimes toxic healthcare practice contexts.
The lived experience presented here is Famke’s account of working as a novice facilitator with clinical nurses and their leaders in an oncology ward, to develop a person-centred culture through participatory action research . A PAR methodology was used, both as a research methodology and approach for facilitation. This was built around key processes of working with practitioners, identifying issues in practice collaboratively and going through cycles of steps for change. Famke’s intention was to promote emancipation and liberation of the practitioners through their own enlightenment. In this way practitioners would be able to undertake democratic strategic action in order to change their practices . Principles of criticality , participation, inclusion and collaboration , creativity  and person-centredness, were used to guide the approach and strategies for facilitation.
After two years Famke observed no progress in the development of practice. Therefore, she decided to move the study from an emancipatory (transformation) methodology to a hermeneutic (understanding) (praxis) methodology in which data about self are used. This move to a hermeneutic study was justified thus. Working with a praxis methodology, which is located in a critical worldview, researchers are perceived as active actors in the process . Their experiences are seen to be of equal value to participants, that is, those with whom they are researching. Therefore, Famke’s experience was part of the data set. In action research, studying others, as well as self, through reflection, is vital so as to develop understanding upon which decisions about action in practice can be made.
analyse the variety of data collected during the action research cycles in practice, using a reflexive framework in order to understand the interplay between context and facilitation,
identify and explore the mediating factors of context that enable or hinder emancipatory change,
develop an understanding of the necessary characteristics of a facilitator in terms of being effective in different contexts.
These objectives guided Famke’s systematic, theoretically-oriented, empirical reflexive analysis on the lived experience of being a facilitator in developing a person-centred culture in healthcare practice. Key messages that surfaced from the analysis were considered in relation to the existing literature, which resulted in identifying a mid-range theory on essential conditions for facilitating practice development/change.
At the final stage of the reflexive analysis, Famke constructed a metanarrative around a sailing metaphor and used interrelated stories that she had previously constructed from the data and analysed with different interpretive teams using critical creative hermeneutic analysis . This resulted in the identification of multiple themes and categories. The metanarrative is a new constructed all-encompassing narrative, in which these themes and categories are interrelated and explained. It reveals the essential meaning of the experience of the challenges of living person-centredness and compassion as a facilitator of transformative research in practice. Famke used the metaphor of sailing in the construction of the narrative to make the experience more universal and concrete for others. Four conceptual areas, identified in the metanarrative, explain the challenges of remaining person-centred and compassionate with others and self, as a facilitator of transformative research. Key messages for facilitation in research and practice are formulated.
A lived experience: Sailing through stormy waters
I started the journey feeling joyful and delighted but also slightly tense, having gone through the breakers and getting acquainted with the enthusiastic crew. Finally being able to fully hoist the sails. While setting course to the open sea, weather conditions changed and the situation became more exciting and demanding. Navigating was pretty tough and challenging due to the heavy sea traffic and navigational buoys were difficult to find. The next couple days, the wind became more powerful and biting. Keeping the boat on course according to the float plan meant sailing close to the wind. It was hard work, because the crew was not as experienced in sailing as I had expected, and time to rest was sparse. The water became rougher, the ride bumpier and I had trouble to get a real feel of the boat and to decide on the right calls for the crew. Although conditions were hard. I knew the rough seas would also give the crew the possibility to learn from the experience and to handle the adverse weather conditions. As conditions deteriorated, I noticed that the crew was somewhat confused and not all were happy with my sailing approach. This resulted in an increase of silence on board and me becoming disconnected from the crew. I felt edgy with this as well as with having trouble sensing the movement and deviations of the boat, resulting in a deplorable lack of progress. I became concerned about our chances to reach our destination.
To wait for better weather seemed to be a waste of time. As an alternative, following my gut, I decided to bear away from the wind for a while, still keeping an eye on the next buoy we were heading for. Energy levels increased again. I plotted the position of the boat by using my navigational charts, and transmitted my coordinates as an indication of where we were to the coastguard. The coastguard transmitted a message back providing me with alternative coordinates to consider. I followed their advice. While I was busy plotting a new position, I observed that the crew was feeling more uncomfortable with the high seas and waves slamming wildly against the hull. Although, I felt responsible as a skipper I didn’t know how I could support them to feel more at ease coping with the conditions. Also, the first mate, often gave me a daunting look while he was busy handling the lines and managing the crew. When inquiring what was wrong, it became apparent that he was annoyed because he did not understand where we were heading. Grazing a sleeping whale when we tacked was not helping to increase that trust either. I began to doubt whether I was truly a skilled sailor and whether I had the right competencies needed for this journey.
When night fell I decided to anchor in a small isle to shelter, to get some rest, to spend some private time with the first mate. We primarily discussed using the on board engine and supervision of the crew’s activities. We didn’t get acquainted on a more personal level, but the talk helped to boost morale on board and working as a team again. Then the weather improved and we headed upwind. Finally, I could live up to the expectations of the journey. Unfortunately, I couldn’t keep to the course as yet again I noticed the wind changing direction and the wind’s force becoming irregular. Also the passage of fronts made for a great deal of sail handling in which I had to stand strong. More than once I noticed the first mate not following my advice and while instructing the crew, he was spilling wind out of the sail. As a result power and boat speed were lost again. I became impatient because our destination was still not in sight.
While I was focussing on the performance of the boat, the weather quickly and unexpectedly deteriorated. There was no time to turn back or seek shelter. I was fighting to keep the boat in position, barely managing as the next wave hit me. I felt the constant struggle between the wind on the foresail and the counteraction of the rudder in my arms. By this stage fatigue was setting in. Standing at the helm, I had almost no energy left to face the storm. To make it worst the boat began to take on water from the high waves and I faced the prospect of sinking and all drowning. The sail was whipping uncontrollably. The next moment the ropes attached to the boom hit me hard on the side of my head; I was knocked over and lost my balance. It was turning into a powerless and out of control situation. The chances of capsizing increased dramatically. I was drifting aimlessly; the crew was exhausted, I was suffering, felt nauseous, helpless, alone and not worthy being a skipper. We found ourselves way off course. I decided it was time to call for immediate assistance from the coastguard.
The crew disembarked at the rescue station and I stayed on board of the damaged boat and was towed back to shore. I was exhausted but extremely happy to have land in sight again. It was quite an experience; facing the storm and raging seas and the challenges it brought about. I’m now lying on the deck under the brightening skies with closed eyes, sensing the water calmly sloshing underneath me. The night before I dropped anchor in a safe haven to recuperate and page through my journal to relive the journey through all my senses. With my close friends I philosophise and reflect on this memorable experience in which the ocean’s power changed my view of the sea and of life.
Conceptual areas in the narrative
The weather and conditions of the sea in the metanarrative, refer to the health care practice context in which facilitation took place. The health care context is inherently complex as it concerns the interplay of culture, leadership, behaviours, relationships and evidence . Culture in particular, is considered to shape the dynamic and changing nature of practice. It is created by human factors and influenced by socio-cultural, political, economic and historical factors, making one setting different from another. It is these cultural characteristics that enhance or inhibit change through tacit rules that guide behaviour, meaning and predictability. Hence culture is often implicit, abstract and intangible. A facilitator engages with the context and becomes directly exposed to the culture in practice. Basic assumptions, values, beliefs and artefacts  become noticeable in the process of learning and challenges the facilitator to understand and work with these, even when they are not fully congruent with their own values and beliefs. As shown in the metanarrative, there is a likelihood for facilitators to become overwhelmed and caught up by this cultural dynamic and complexity, and in particular when attention to humanity and compassion is poor within the organisation.
By practising sailing more often, you will come to know that the weather is not static, and changes at any time. Sailing requires experience in varying wind and sea conditions. As a sailor you need to enter open water, to read the weather, and only then can you decide on appropriate sailing strategies and support of the crew to adapt to specific circumstances.
In the metanarrative, balance refers to the counteraction between the boat and Famke, as the skipper, handling the rudder and keeping the boat in balance. This concept is about facilitators constantly trying to adapt their approaches and strategies to suit the context. The metanarrative shows a constant tension between principles underlying the research methodology, those of context and those personal to the facilitator. This caused imbalance for Famke, losing ground and bringing up emotions of uncertainty, loss of self-confidence and poor compassion to self and the crew. These in turn had an effect on the focus, levels of energy, relationship building and ultimately the progress of the study.
It is evident that the role and skills or the ‘doing’ of facilitation cannot be separated from the person, the ‘being’, of the facilitator. Personal values and characteristics are an intrinsic, original part of the facilitator and influence a facilitator’s perception and actions. As well as technical skills, intra –and interpersonal skills are also important in the effective facilitation of change . In engagement with others, the facilitator’s inner landscape of values and beliefs comes to the surface and impacts on choices for actions. As already mentioned, values and beliefs in context may conflict with those of the facilitator resulting in a constant tussle between the two, while trying collaboratively to decide on actions. So the characteristics of the facilitator may enable or hinder flexible working with these different, sometimes polarised values. In the metanarrative, a strong tenacity on ‘doing’ and less on ‘being’ resulted in self-destruction, exhaustion and not staying true to values of criticality, participation, person-centredness and compassion that were espoused in the study.
Awareness of self, becoming grounded in one’s own personal system of values and beliefs and developing emotional intelligence, are essential for a facilitator to understand and give meaning to a situation. These three capacities give facilitators space for their own emotions. In turn, that creates space for untangling incongruent values within themselves, doing something about it and recognising their potential, as well as limitations. This personal development work enables the facilitator to respond flexibly to contextual dynamics and complexity. Such flexibility will lessen the likelihood of the facilitator being buffeted, helplessly by the turbulence of the context, being unkind and blaming towards oneself and therefore having less or no energy with which to support others, which might result in becoming impatient with them.
In sailing, a strong undercurrent can knock you off balance and off course. It could help to hold the rudder firmly and trim the lines, but this is mostly exhausting work.
It would be better to drop anchor and explore how to cope with the undercurrent, to regain balance and so to continue the journey.
Conceptual area of support
The coastguard in the metanarrative is symbolic of a person-centred system of support, which is compassionate. In this study, the support consisted of a team of academic supervisors and critical friends who were present during the entire period of the study. They helped Famke on her journey of personal and professional development through enabling her to understand: the nature of the context; herself as a novice facilitator; the interplay between these concepts and; how this interplay had influenced her strategies for action. This support provided reflexive spaces for Famke to work through her pain and confusion. She became able to articulate the feelings of loneliness, self-doubt and emotional despair that she had experienced as a novice facilitator in a turbulent context. She became more open for self-criticism, engagement in meaningful reflexive action and mutual learning and development of new understandings for future, shared action.
Reflexivity takes more than one person to show the self to self and to mirror wisdoms back to oneself . In this study, a variety of peers in the system of support was essential to bring their different ways of knowing into the mix and so generate, in the reflexive analysis, new insights. The use of creative arts to surface these different ways of knowing, was perceived to be effective by all involved.
In sailing you need to plan, prior to your journey, which harbours you might need to enter to stock up on supplies, to meet fellow sailors to share stories, to keep morale high, to take a break, to help adjust course if the weather changes for the worst and to repair possible damage.
Conceptual area of synchronicity
You cannot change the wind, though you can change course and the position of your sails
Person-centred practice and compassion are known to manifest differently in different contexts .
The study demonstrated that person-centredness cannot be taken for granted, nor is it a static entity in facilitative relationships. Compassion, as an interpersonal phenomenon within person-centred practice, was also shown to be a valuable, yet fragile and fluctuating relational concept, which could be challenging for facilitators to retain and develop further in real-world practice. Responses to feelings of compassion towards oneself and others were frequently hindered by a lack of understanding of the dynamic interplay between the context in which compassion was often absent and the facilitator’s understanding of the situation. This lack of understanding resulted in the facilitator often ignoring and supressing compassion. The outcome was that the facilitator became imbalanced and no longer able to show compassion to others and to help others in developing their practice. Therefore we consider, a person-centred, compassionate focus in the facilitation relationship, to be pivotal in the enabling of humanistic practices. This indicates that the relational and emotional characteristics of facilitation are as significant as its technical nature. Hence, facilitators need to constantly reflect on their relationships in order, to gain an understanding of how practice cultures impact on themselves and on their engagement with others throughout the process, and so ultimately on their facilitation. Such reflection in and on action is necessary for if synchronous development is to be achieved between facilitator and context.
The findings also indicate that a compassionate system of support is of value in taking time for this reflection and learning to occur on a regular basis. This assertion builds on the assumption that learning about self and context is a joint process in which multiple perspectives on an issue can be shared, embodiment of values can be enhanced and expertise developed . The study suggests that learning within these systems of support needs to be focussed on helping facilitators to adopt a genuine whole-self approach, in which they appreciate paradoxes in their ‘being’ and remain compassionate to themselves which, in turn, may make it easier for them to show compassion in their ‘doing’ with others.
It was found that a variety of professionals can take part in a compassionate system of support. It is proposed that this can be a uniform or multi-disciplinary group, with ‘insiders’ coming from within the practice context or with ‘outsiders’ from outside. ‘Insiders’ could refer to clinical leaders or to collegial practitioners as was the case in this study, whilst ‘outsiders’ could be expert consultants or other researchers. A compassionate system of support could be located within a research or supervision team or in ‘communities of practice’ [28, 29], as in this study. Such communities are characterised by openness, personal connectedness and familiarity to the context. Their aim is to shape, and contribute to, the mutual learning so central to participative active research and the growth of practitioners and facilitators. Critical, reflective spaces are created in which ‘communing’ and learning can take place around specific learning needs through strategies that stimulate the use of all available sources of knowing, such as, action/active learning, storytelling and use of creative arts media .
A system of support in a context of facilitation could be perceived as a ‘luxury’ and an unrealistic proposition for health care practitioners working in the ‘swampy lowlands’  of practice. However, practitioners may identify with the experience, issues and concepts illuminated in this study, as they engage with others in developing their clinical practice. This supposition is strengthened by Fitzgerald et al’s  research in which practitioners acted as peer facilitators in practice to implement a CARE approach in practice. For a system of support as suggested in this study, which could include peer facilitators, there is no particular need for recruiting expensive external supporters, which is normally more common, to create effective and trusting relationships for developing professional expertise, as supporters can also be found in the direct practice environment. Hence, the value of a compassionate system of support can be argued to be a realistic proposition for health care practitioners to become the reflexive and flexible professionals  that current health care needs.
Conclusions and implications for policy and practice
What would you do if I sang out of tune?
Would you stand up and walk out on me?
Lend me your ears and I’ll sing you a song
I will try not to sing out of key
From: ‘With a little help of my friends’ [Joe Cocker]
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