Improving the discharge planning process

The focus of the assignment is to improve the discharge planning process through the development of an integrated care pathway (ICP). The author’s client group relates to care of children and adolescents with cancer, aged 0-21 years, the multidisciplinary team including nurses, doctors, physiotherapist, dietitian, social worker, community liaison nurse, palliative care team, the patient, carer, other specialist nurses and outside agencies including primary care teams. The rationale for development will be highlighted, followed by critical analysis of the implications of implementing the proposed change, which will be addressed from a specialist practitioner perspective. Management and Leadership strategies that would be employed by the Specialist Practitioner will be discussed, followed by critical evaluation of the proposal.

The recommendation chosen from the NHS, Modern, Dependable (DOH, 1997), relates to improving integration and collaboration, proposed as an integral part of future patient care. The reason for choosing the recommendation is the increasing importance for NHS staff to work efficiently and effectively in teams within and across organisational boundaries.

Maloney and Preston (1992) highlight the acute and chronic nature of cancer can profoundly affect quality of life, the period following discharge being one of great vulnerability and anxiety. Planning care, providing adequate information and involving clients can minimise distress and disruption.

In relation to the health needs of the specific client group, children and adolescents with cancer move through many healthcare settings during the course of their illness, encountering numerous healthcare professionals. Maloney and Preston (1992) indicate successful transition through these settings is dependent upon the collaborative efforts of healthcare providers.

Scott and Cowen (1997) assert a collaborative model of care assists in breaking down professional barriers, enhancing communication and increasing awareness of individual roles. This is important, Smith (1996) identifying that interprofessional conflict often results from differing role perceptions.

The proposed change is to improve integration and collaboration of care for the entire client group through the development of an ICP. Lowe (1998) proposes this offers the potential to involve all relevant professionals, care-givers and clients in decision-making and co-ordinating care across the primary/secondary interface. Hotchkiss (1997) believes it offers a system of multidisciplinary care planning based around the principles of clinical audit, providing a system for effective monitoring and evaluation of the discharge process.

The specialist practitioner role involves identification and examination of the wider issues contributing to the problems of current discharge planning to provide a rationale for change. As Maloney and Preston (1992) indicate, historically, care was provided at home until the advent of the NHS in 1948 shifted primary care responsibilities from family to professional care-giver. They believe a cyclic phenomenen has resulted in transition of care back into the community, but with increased responsibilities and changing family structures, requiring effective discharge planning to meet the challenge of increasing and complex needs.

Macmillan (1994) discusses that demographic changes alongside advances in healthcare have resulted in an ageing population, of which Nazarco (1997) highlights, a growing number will develop cancer. Whilst this does not relate specifically to the client group, it is relevant as it has a major impact on the organisation’s resources, the paediatric unit being within an adult cancer centre. Coupled with this, an overall survival rate of 65% in childhood cancer, has shifted the focus from an incurable disease to supporting a child with a chronic illness (Gibson and Evans 1999), another major resource issue.

Macmillan (1994) discusses the shift in focus from hospital to community, which, coupled with increasing pressures on beds and the average length of stay being measured in terms of efficiency, have produced quicker and sicker discharges. She argues that these parameters, whilst taken as indicators of good management, often conflict with the desire to see clients safely returned to the community.

Currently, a lack of integration and collaboration results in poor communication and documentation which leads to duplication or omission of services, fragmentation of care, delays in discharge, increased pressure on beds and NHS resources, complaints and critical incidents. Wilson (1998) identifies that documentation and communication regularly let practitioners down in the discharge process. Wiffin (1995) substantiates this view highlighting that record-keeping studies show nursing records often lack information relating to the individuals home environment and previous level of functioning, whilst King and McMillan (1994) suggest information obtained is often inadequate for making informed discharge decisions. Mantel (1995) concludes documentation is a key issue, the best legal protection resulting from effective record-keeping. The need for comprehensive and co-ordinated discharge planning has therefore never been greater.

Maloney and Preston (1992) propose ongoing communication is the key and foundation upon which successful collaboration is built. Indeed, Smith (1996) identifies interprofessional communication as a significant factor in providing patient-centred care and ensuring a seamless transfer from hospital to community. Victor (1991) supports this viewpoint, highlighting poor communication leads to difficulties co-ordinating members involved in the discharge planning process. Currie (1999) advocates the development of an (ICP) for discharge planning may improve communication and enhance client involvement.

Government initiatives to address discharge problems place increasing emphasis on collaboration and integration of services, and the development of effective Partnerships, resulting in a shifting balance from acute sector to community (DOH, 1990, DOH, 1997, DOH, 1998).

Fletcher and Buka (1999 ) believe the increased focus on primary healthcare and a greater patient-focus gives rise to ethical questions of autonomy on the part of the client and practitioner, with care needing to be negotiated to achieve a successful outcome. They suggest this includes respecting the right of individuals to make decisions for themselves even if those decisions are not congruent with others goals, which may involve conflict, choice, values and conscience.

In implementing the change, the specialist practitioner must state clearly what is to be achieved. The vision is one of integrated, patient-focused care, provided through collaborative working. Nazarko (1998) proposes this requires examination of internal structures and external influences. This relates to the organisation’s structure and culture, access to resources, potential barriers to change and possible facilitators, economic and political factors. Determining the power base is an important element of the specialist practitioner role to recognise who has the influence over the proposed change. The main thrust for improving documentation stems from the management structure, in particular the clinical governance and risk management agenda. However, the corporate position is to strengthen leadership and involve staff in decision-making. Staff would therefore direct the way the proposed change could be achieved. This supports the argument advocated by McCormack et al (1999) that successful change needs to be practitioner owned and organisationally supported. They also propose successful change needs to be undertaken using a systematic approach. Lewin’s (1951) force field analysis provides a framework for problem solving and planning change, through identification of driving and restraining forces.

Force field analysis enables the Specialist Practitioner to make a correct assessment of the forces present important to the change process, understand how they affect one another, determine how goals can be met and shift the balance in the direction of change. This requires identification of appropriate strategies for the client group and relates to the first stage of Lewin’s change theory, known as unfreezing (Lewin,1951), which prepares people for change. Allen (1993) suggests unfreezing occurs by increasing the driving forces whilst decreasing the restraining forces thus reducing resistance to change. The specialist practitioner needs to involve everyone concerned in developing a shared vision and commitment, establish open communication channels at all stages, select optimal change strategies, lead and apply all components of dissemination and implementation strategies.

Broome (1998) proposes creating a culture of change and innovation is relevant to leadership issues. Sofarelli and Brown (1998) advocate transformational leadership, an empowering style that works on ideas and visions, and builds common commitment. Research has reported transformational leadership to be positively tied to job satisfaction and organisational commitment. (Morrison et al, 1997, Stordeur et al, 2000). Sofarelli and Brown (1997) suggest this style is ideally suited to the present climate in actively embracing and encouraging innovation and change. Girvin (1996) however, suggests transformational leadership may not be so effective when used alone and in fact acts as an enhancer of transactional interventions, which concentrates on achieving the task, building and maintaining the team and developing the individual. Adair (1988) argues that leaders are most effective when they address all three functions simultaneously. McCormack and Hopkins (1995) believe these aspirations are best achieved when leaders function in a collaborative and collegial way.

In developing an ICP for discharge, a combination of both styles would be useful. Utilising a transformational style, the specialist practitioner can provide the leadership qualities and motivation for multidisciplinary team members to become innovative in viewing problems and solutions. This is increasingly important as the focus shifts from hospital to community and staff must ensure the client is adequately prepared for discharge. The transactional element will ensure the task as well as the team and individual are considered, important in moving the proposed change forward and achieving the desired objectives within a given timescale.

Stordeur et al (2000) asserts the hospital’s structure and culture are major determinants of leadership styles and the key to successful change is excellence in leadership at both clinical and managerial level. The organisation however, needs to be ready for this commitment as it moves away from the traditionally hierarchical approach inherent within the organisation for many years, the power base still evident within the medical profession. Preparation is therefore a major aspect of the specialist practitioner role. The Trust is developing active strategies and investing in the development of effective leadership and the Specialist practitioner needs to act as role model, developing a positive culture whereby staff are pro-active and interactive.

Rocchiccioli and Tilbury (1998) advocate a collaborative care model maximises staff contribution to patient care. The model reflects a participative management style, linking well with a transformational style of leadership, assisting in integrating services (DOH 1998), improving communication processes, establishing clear lines of accountability and empowering staff to take ownership of their own roles. Clutterbuck (1994) believes shared vision is vital for the learning organisation, helping individuals develop an appetite for beneficial change in terms of behaviour and skills that stick. He suggests empowerment is a tool that can help bring this about. This requires creation of a culture which both encourages people at all levels to feel they can make a difference and help them acquire the confidence and skills to do so.

Doherty and Hope, (2000) advocate the philosophy of shared governance relates to a decentralised style of management that creates an environment of empowerment. Geoghegan and Farrington (1995) discuss the benefits of this approach, recognising that it gives nurses collective responsibility and accountability for practice by moving away from the traditional “management” hierarchical style to one where staff are more involved in decision-making processes and managers have a facilitative rather than controlling role. They assert this will increase morale, motivation and staff contribution, encourage creativity, promote interpersonal relationships, ownership and a sense of value. On a macro level, this could impact on professional development, recruitment and retention.

Involving staff in service development and planning change with open communication and collaboration is a central vision of current UK govt (DOH, 1997 NHSE, 1999). The multidisciplinary team need to work collaboratively to ensure effective utilisation of existing service provision. The Specialist Practitioner can assist in defining individual roles and facilitating ownership to minimise resistance. This supports a normative-re-educative approach to change, which Andrews (1993) suggests is most effective if the change is to be long term and beliefs and attitudes altered. Sullivan and Decker (1997) propose it rests on the assumption that people act in accordance with social norms and values, and in contrast with the empirical-ration approach, information and rational arguments are insufficient strategies to change people’s patterns of actions. The specialist practitioner must therefore focus on behaviour as well, as relationships, attitudes and feelings will influence acceptance of change. As Sullivan and Decker (1997) indicate, in this mode, the power ingredient is not authority or knowledge, but skill in interpersonal relationships. Rocchiccioli and Tilbury (1998) advocate the leadership style for a normative re-educative approach is participation, communication, education and collaboration. This reflects the philosophy of shared governance and links well with a transformational style of leadership. It is therefore a useful strategy, but used alone may be insufficient to sell the change in practice to the multidisciplinary team. An empirical-rational approach during initial stages may assist in persuading the team to accept a rationally justified change that will benefit both themselves and the client (Sullivan and Decker1997), important as these benefits will become the major driving force for accepting change. A mix of strategies would also suit the organisation’s commitment to a bottom up and top down approach, Wright (1996) emphasising an empirical-rational strategy is essentially top down, whilst the normative re-educative strategy supports a bottom up change strategy.

During the moving stage, the specialist practitioner role involves planning and implementing the change, requiring consideration of how the ICP will be formatted, who would be involved and what roles they will perform. Conducting a focus group of relevant personnel will ensure multidisciplinary input into its development. Time must be allowed for support, discussion, evaluation and feedback, with open communication at all stages. The ICP would then be piloted prior to implementation, final adjustments made and a decision taken if it could be used in other areas, which may help sell the change to the multidisciplinary team and management.

Once participants integrate new patterns of behaviour, a refreezing takes place. (Sullivan and Decker, 1997). The specialist practitioner role would be to monitor the effects of the change and prepare to alter or adapt plans as necessary, using ongoing communication, so problems can be identified and addressed as quickly as possible. Otherwise there is a danger that staff will revert to previous practices and the change be less effective. Lewin (1951) identifies this stage as the refreezing process, the final stage of the change process.

Consideration needs to be given to the strengths and weaknesses of implementing and establishing the proposed change in practice. This requires exploration of potential driving and restraining forces that may influence acceptance of the change. Examination prior to introducing change enables the specialist practitioner to minimise potential restraining forces and make effective use of facilitators which may drive the process.

The specialist practitioner must consider economic and political factors. Many changes are resource driven due to the need for cost-effective healthcare and introducing change requires examination of resource issues. One major Political strength is integrated care replacing the internal market with a system of collaborative care delivery, involving teams working more in Partnership (DOH,1997). This is important, the development of an ICP for discharge relying on the collaborative efforts of all healthcare providers to ensure a smooth transition from hospital to community. The literature highlights potential benefits, which on a macro level may be seen in terms of improved quality of care and patient satisfaction (Hotchkiss 1997). Cost-benefit advantages may also emerge; a reduction in the incidence of preventable disease and length of hospital stay (Kitchiner 1996), lower re-admission rate (Lowe 1998), earlier recovery and more efficient use of resources (Currie 1999), all of which fit well with the corporate agenda.

The literature, coupled with the thrust from government initiatives therefore provide clear benefits and opportunities for the development of an ICP for discharge. One weakness identified by Currie (1998) is that, as yet, there is a lack of systematic research into care pathways as to their effect on patient outcomes, but Kitchiner et al (1996) highlight their potential as a powerful audit tool.

Shared governance is an important opportunity as a driving force, Geoghegan and Farrington (1995) highlighting its potential for enhancing staff involvement in decision-making. Government initiatives also provide an important opportunity in strengthening the nursing contribution (DOH,1999). Geoghegan and Farrington (1995) recognise setting up a shared governance system within an organisation is an enormous task. One current strength is the organisation actively embracing the concept of shared governance and investing in the development of effective leadership. The Trust is moving towards a process oriented organisation, described by Scott (1999) as a decentralised system of management where communication is bottom up and top down and the patient at the centre of the care delivery process. This relates well to the chosen strategies that would be employed by the specialist practitioner to implement the ICP for discharge.

An important restraining force to consider is the hierarchical culture still prevailing within the medical profession. A mix of leadership styles would therefore work better because of the culture and personalities still evident within the organisation, which can pose great barriers to change. Doherty and Hope (2000) indicate that to ensure lasting change, a slow evolutionary approach to implementing shared governance is necessary, requiring persistence and determination. The specialist practitioner role would be to examine behaviours and attitudes, identify what influences them and how they may be changed or addressed. Sometimes the barriers come from individual staff who carry out care in a controlling rather than empowering way, perceiving what is in the best interests of the patient rather than identifying individual needs.

Some staff find it difficult to be non-judgemental and objective working with families whose behaviours and attitudes conflict with our own. This can pose ethical dilemmas in allowing the individual to control their own lives whilst still trying to facilitate what they consider to be in the client’s best interest. Healthcare professionals need to develop effective communication networks in which the client is fully involved in decision-making, negotiating care to achieve a successful outcome. Whyte and Smith (1997) highlight that this is of vital importance particularly within the adolescent age group in which locus of control is important in achieving compliance. An ICP for discharge will assist this process. One potential driving force is staff commitment to a patient-focused care model in which choice and control are important considerations.

On a macro level, a potential weakness is patients and staff don’t always consider the health-within-illness concept, which Moch (1998) suggests can provide the opportunity for positive change. The specialist practitioner needs to ensure nurses are fully aware of their role as health educators. This is important as nurses are uniquely positioned to assist clients with a chronic illness such as cancer, in the process of health-within-illness, an important consideration to promote optimum self-care measures. Other challenges must also be confronted such as re-entry into school, and as DuHamel (1999) indicates, resuming normal interaction with peers is an important process in promoting optimal rehabilitation. A chronically ill child with cancer may spend long periods of time in hospital and interaction with peers is often affected. The implementation of an ICP for discharge will facilitate early consideration of important issues and development of effective partnerships with outside agencies who can assist the process as early as possible.

Whilst government initiatives support reducing inequalities in health (DOH,1997), there are still constraints for some families who do not have the genuine freedom to choose a healthier lifestyle. The Specialist Practitioner role is to assist the health educator in raising awareness of the wider factors determining health choices, so the client feels significant control resides with themselves. Also, whilst empowerment is an important consideration, some clients may not want to be empowered, in which case, empowerment can be disempowering. Consideration needs to be given to each individual family incorporating cultural differences, language barriers, and specific individual needs. It is important that individual needs are acknowledged and supported by the multidisciplinary team. An ICP for discharge will assist this process, facilitating a smoother transition from hospital to community.

Clinical Governance is an excellent opportunity as a driving force. It will assist in breaking down barriers within the organisation and social care system so patient’s needs are dealt with holistically, important in ensuring a seamless transition into the community. It demonstrates an open, participative culture, commitment to quality, patient involvement and an ethos of multidisciplinary teamworking at all levels in the organisation, all of which are vital in the development of an ICP for discharge. It reflects the principles of shared governance in that professionals are provided with the responsibility to take on the task, the authority to make changes and establishes leadership and accountability so everyone is aware of their role. It is therefore ideally suited to the chosen strategies that would be employed by the Specialist Practitioner in implementing the change. One potential constraint within the Clinical Governance process is highlighted by Scott (1999), who proposes that it still primarily generates a model of medical governance, which sits well with the power culture still evident within the organisation. The specialist practitioner in adopting appropriate leadership strategies and supporting nurses to acquire the competencies and skills required to enhance their influence and participation, will assist in changing this into a driving force.

Accountability issues could be a potential restraining force with the current diversity of roles causing duplication, omission and fragmentation of care. The commitment to multidisciplinary working is evident and the development of an ICP would assist the integration of documentation which would improve communication processes. The specialist practitioner would need to ensure the ICP clarified the scope and remit of each individual role, established clear lines of accountability and empowered staff to take ownership of their own roles.

Enlisting support of the multidisciplinary team would be vital to ensure effective utilisation of existing service provision and clarification of individual roles. Ashford et al (1999) advocates that utilising existing skills and knowledge of staff enhances role development, an important consideration, as who is involved and what roles they perform can influence the success of implementation strategies. This will also promote interaction of individuals within the multidisciplinary team important if effective collaboration is to take place and the management and leadership strategies identified are to be utilised effectively.

The multidisciplinary team need to be actively involved in the change process, willing to accept new ways of working, and if they are to be motivated, must see the perceived benefits to the patient and believe the process will work. Utilising a mix of change strategies incorporating both an empirical-rational and normative re-educative model may assist this process. This will combine the power ingredient of knowledge and rational thought in persuading staff of the benefits of the proposed change, and skill in interpersonal relationships, which focuses on behaviour, attitudes and feelings to influence the acceptance of change. (Sullivan and Decker, 1997).

The Specialist Practitioner would need to consider training and education issues and develop effective strategies to support understanding, ownership and acceptance of the proposed change. This would require acting as facilitator and coach, bringing staff together and motivating them to achieve change. Whitmore (1996) identifies this would create the right learning environment to unlock individual staff potential, an important element of the empowerment process. It sits comfortably with the strategies identified to take the proposed change forward, reflecting both a participative management style and relating to the qualities identified in transformational leadership. Otherwise, there is a danger staff will revert to previous poor practice and fail to make effective use of the new documentation. This relates to Lewin’s third and final stage of the change process, identified as the refreezing process. (Lewin, 1951). At this stage behaviour moves to a new level at which the opposing forces are brought into a new state of equilibrium and new patterns of behaviour are integrated (Sullivan and Decker, 1997).

In Conclusion, the implementation of an ICP for discharge will assist in establishing a patient-focused collaborative model of care, aid integration of services and help to co-ordinate care more effectively within and across organisational boundaries. Utilisation of effective change management, and management and leadership strategies will assist its development, ensuring the patient is put at the centre of the care process.

References.

Adair, J. (1988). Effective Leadership. Pan. London.

Allen, A. Changing theory in nursing practice. Senior nurse. Vol.13. no.1. Jan/Feb.1993. pp43-45.

Andrews, M. Importance of nursing leadership in implementing change. British Journal of Nursing. Vol.2. no.8. 1993. pp437-439.

Ashford, J. Eccles, M. Bond, S. Hall, L.A. and Bond, J. Improving health care through professional behaviour change: introducing a framework for identifying behaviour change strategies. British Journal of Clinical Governance. Vol.4 no.1. 1999. pp14-23.

Broome, A.(1998). Managing change: Essentials of nursing management. 2nd Edition. MacMillan Press. London.

Clutterbuck, D. (1994). The power of empowerment. BCA. London.

Currie, L. Researching care pathway development in the United Kingdom: Stage One. NT Research. Vol.4. no.5. 1999. pp378-385.

Department of Health (1990). NHS and Community Care Act. London. HMSO.

Department of Health (1997). The New NHS. Modern, Dependable. London. HMSO.

Department of Health (1998). Transforming Children’s Services. London. HMSO.

Doherty, C. and Hope, W. Shared Governance-nurses making a difference. Journal of Nursing Management. 8. 2000. pp77-81.

DuHamel, K.N. Redd, W.H. and Johnson Vickberg, S.M. Behavioural interventions in the diagnosis, treatment and rehabilitation of children with cancer. Acta Oncologica. Vol.38. no.6. 1999. pp719-734.

Fletcher, L. and Buka, P. (1999). A Legal framework for caring. An introduction to Law and Ethics in Healthcare. MacMillan Press. London.

Geoghegan, J. and Farrington, A. Shared Governance: developing a British model. British Journal of Nursing. Vol.4. no.13. 1995. pp780-783.

Gibson, F. and Evans, M. (1999). Paediatric Oncology. Acute nursing care. Whurr Publishers. London.

Girvin, J. Leadership and Nursing: Part two: styles of leadership. Nursing Management. Vol.3. no.2. 1996. pp20-21.

Hotchkiss, R. Integrated care pathways. NT Research. Vol.2. no.1. 1997. pp30-37

King, C. and MacMillan, M. Documentation and discharge planning for elderly patients. Nursing Times. Vol.90. no. 20. 1994. pp31-33.

Kitchiner, D. Davidson, C and Bundred P. Integrated care pathways: effective tools for continuous evaluation of clinical practice. Journal of evaluation in clinical practice. 2. 1. 1996. pp65-69.

Lewin, K. (1951). Cited in Thomson, R. (1993) Managing People. pp169-170. Butterworth-Heinemann. Oxford.

Lowe, C. Care Pathways: Have they a place in the New National Health Service? Journal of Nursing Management. 6. 1998. pp303-306.

MacMillan, M.S. Hospital staff’s perceptions of risk associated with the discharge of elderly people from acute hospital care. Journal of Advanced Nursing. 19. 1994. pp249-256.

Maloney, C..H. and Preston, F. An overview of home care for patients with cancer. Oncology nurses forum. Vol.19. no.1. 1992. pp75-80

Mantel, D. L. The legal perils of discharge. RN. 1995. pp49-51.

McCormack, B. Manley, K. Kitson, A. Titchen, A. and Harvey, G. Towards practice development-a vision in reality or a reality without vision? Journal of Nursing Management. 7. 1999. pp255-264.

McCormack, B. and Hopkins, E. The development of clinical leadership through supported reflective practice. Journal of Clinical nursing. 4. 1995. pp161-168.

Moch, S. D. Health-within-illness: concept development through research and practice. Journal of Advanced Nursing. 28 (2) 1998. pp305-310.

Morrison, R.S. Jones, L. and Fuller, B. The relation between leadership style and empowerment on job satisfaction of nurses. Journal of nursing administration. 27 (5). 1997. pp27-34.

Nazarko, L Improving hospital discharge arrangements for older people. Nursing Standard. 11. 40. 1997. pp44-47.

Nazarko, L. Improving discharge: the role of the discharge co-ordinator. Nursing Standard. Vol.12. no.49. 1998. pp35-37

NHSE, (1998). Unlocking the Potential. Effective partnerships for improving health. London. HMSO

NHSE, (1999). Making a Difference. London. HMSO.

Rocchiccioli, J. and Tilbury, M. 1998. Clinical Leadership in Nursing. Saunders. London.

Scott, E. and Cowen, B. Multidisciplinary collaborative care planning. Nursing Standard. 12. 1. 1997. pp39-42.

Scott, I. Clinical Governance: an opportunity for nurses to influence the future of healthcare development. NT Research. Vol.4. no.3. 1999. pp170-176

Smith, S. Discharge Planning: the need for effective communication. Nursing Standard. 10.38. 1996. pp39-41.

Sofarelli, D. and Brown, D. The need for nursing leadership in uncertain times. Journal of Nursing Management. 6. 1998. pp201-207.

Stordeur, S. Vandenberghe, C. and D’Hoore, W. Leadership styles across hierarchical levels in nursing departments. Nursing Research. Vol.49. no.1. January/February 2000. pp 37-43

Sullivan, E. J. and Decker, P. J. (1997). Effective Leadership and Management in Nursing. 4th Edition. Addison Wesley Longman. Menlo Park.

Victor, C. (1991). Health and health care in later life. Buckingham. Open university press.

Whitmore, J. 1996. Coaching for Performance: The new edition of the practical guide. 2nd Edition. London.

Whyte, F. and Smith, L. A literature review of adolescence and cancer. European Journal of Cancer Care. 6. 1997. pp137-146.

Wiffin, A. An assessment of procedures. Nursing Times. Vol.91. no. 28. 1995. pp31-32.

Wilson, J. Proactive risk management: Documentation of patient care. British Journal of Nursing. Vol.7. no.13. 1998. pp797-798.

Wright, S.G. The need to develop nursing practice through innovation and practice change. International Journal of Nursing practice. 2. 1996. pp142-148.

Bibliography.

Marriner-Tomey, A. (1996). Nursing Management and Leadership. 5th Edition. pp169-182. Mosby. USA.