Nursing Professional Development Facilitation

Issues of Concern

The following section discusses the utilization of facilitation strategies, facilitation in implementation science, and examples of facilitation with different groups.

General Facilitation Resources and Strategies

Butler and colleagues developed a program to facilitate the development of novice NPD practitioners (NPDP) using the expertise of experienced NPD specialists.[2] The program aimed to support NPDPs in their transition role by providing a comprehensive online repository of learning resources that demonstrated different presentation methodologies and offered support tailored to the needs of those new to the position.

To ensure the program's effectiveness, a learning needs assessment was conducted to identify the current learning needs of novice NPDPs and gather input regarding the content required to support their development. A diverse work team consisting of 6 NPDP experts was then assembled. This team encompassed a wide range of nursing experience, ranging from 7 to 44 years, and educational background, ranging from 2 to 25 years. The team represented different generations, including baby boomers, Gen-Xers, millennials, and individuals categorized as technology immigrants and natives.

The created program, the Educator Academy, was organized into various categories, including educator role, learning principles, instructional design, competency, onboarding, and advanced skills. The academy was structured into 3 phases. The first phase concentrated on providing fundamental knowledge and skills that novice educators require early in their role transition. The second phase, approximately 6 months to 1 year after the role transition, covered intermediate content, such as utilizing technology for learning and meaningful evaluation. The third phase, still under development, was designed for NPDPs at least a year after their initial role transition and included advanced concepts such as research and writing for publication.

Throughout the program, multiple presentation strategies were utilized to demonstrate the practical application of various tools and approaches. Participants provided feedback and reflected on their experiences at the end of the program.

Reflection is a critical component of NPD practice and serves as a strategy for learning through practice. Miraglia & Asselin conducted an integrative review examining reflection as an NPD educational strategy.[3]  Reflective education is often structured with group facilitation in programs and employed to achieve specific clinical goals.

The authors analyzed a wide range of literature on using reflection in NPD as an educational strategy and examined the reported outcomes. After a thorough review of 553 articles, 25 met the inclusion and exclusion criteria and were included in the integrated review. The final sample of articles represented perspectives from 8 different countries.

Two prominent themes emerged from the analysis concerning the goal of reflection education. The first theme involved using a reflective strategy to meet specific clinical goals, while the second theme focused on teaching nurses how to reflect to enhance their reflective practice. The reflective group discussion theme focused on using a facilitator to guide the reflective dialogue. Some articles described applying a reflective framework on a model, while others emphasized using questions developed by researchers or educators to guide the reflective process.

Nurses expressed positive feedback regarding the impact of using reflective strategies, indicating that reflection influences clinical practice at individual and organizational levels. Reflection enhances knowledge and impacts assumptions, values, and beliefs, ultimately informing clinical practice. At the organizational level, reflection empowers nurses to explore practice concerns, leading to practice change. Interprofessional teams play a significant role in influencing practice change at the organizational level.

Facilitation in Interprofessional Education

Interprofessional education (IPE) is critical in preparing healthcare professionals to work collaboratively and effectively in today's complex healthcare environment. Within the realm of IPE, 4 competencies guide the learning process. These are (1) roles and responsibilities, (2) values and ethics, (3) communication, and (4) teams and teamwork.

NPD practitioners play a crucial role in supporting and facilitating IPE activities. When planning IPD activities, NPD practitioners must consider these competencies to ensure learners have the necessary skills to engage in collaborative practice.

Ideally, facilitators involved in IPE activities should represent diverse healthcare disciplines to provide a comprehensive and inclusive learning experience. If learners are divided into groups for activities, each group should have representatives from various professions to foster interprofessional collaboration and understanding.

Facilitators must demonstrate appreciation and respect for all members of the healthcare team. By role modeling interprofessional leadership behaviors, facilitators enable students to witness the collaborative nature of joint leadership. This, in turn, promotes trust and acceptance of the interprofessional practice.

To assist in the facilitation of IPE learning and the development of positive team functioning, Von Diggele and colleagues have identified several helpful tips, including:[4]

1. Structured early orientation to IPE
2. Role of other professions
3. Questioning
4. Focus on the needs of patients
5. Trust
6. Flipped classroom approach
7. Be a facilitator, not a lecturer
8. Peer learning
9. Review and reflect
10. Assessment and feedback

Integrating facilitation into IPE can enhance leadership, collaboration, and communication among healthcare teams, ultimately improving patient safety. Furthermore, implementing research and evidence-based practices at the organizational level significantly enhances patient safety. 

 Facilitation in Implementation Science

Implementation science is "the scientific study of methods to promote the systematic update of research findings and other evidence-based practice into routine practice and, hence, to improve the quality and effectiveness of health services." The primary objective is to identify the factors influencing the adoption of evidence-based practices in everyday clinical settings.[5] 

The Integrated Promoting Action on Research Implementation in Health Services (I-PARIHS) framework, derived from the PARIHS framework first published in 2008, is an organizational and conceptual framework widely utilized to help explain and predict the success or failure of evidence implementation in practice. This revised framework emphasizes the central role of facilitation in the implementation process. Facilitators employ various skills and improvement strategies to structure the implementation process, foster stakeholder engagement, manage relationships, and identify implementation barriers.[6][7] 

A qualitative study by Ritchie et al explored the transfer of facilitation skills of an expert external facilitator to 2 novice internal facilitators. Through monthly interviews conducted over 30 months, researchers transcribed 2 qualitative interviews with each facilitator: one at the 16-month mark, focusing on training content and process, and the other at the conclusion of the study. Based on this data, the authors identified and described 22 implementation facilitation skills transferred from the expert facilitator to the novice internal facilitators. These skills exhibited complexity and overlapped with one another. One skill identified was effective communication, while the remaining 21 skills were further classified into 5 overarching skillsets, which encompassed:

1. Building relationships and creating a supportive environment
2. Changing the system of care and structures and processes that support it
3. Transferring knowledge and skills and creating infrastructure support for ongoing learning
4. Planning and facilitating change efforts
5. Assessing people, processes, and outcomes and creating infrastructure for program monitoring

Using Interpersonal Skills to Facilitate

Although implementation facilitators support healthcare staff in implementing change, there is little knowledge about the affective experiences, encompassing emotional, mental, and physical, of facilitation. To address this gap, Olmos-Ochoa and colleagues expanded the I-PARIHS framework by incorporating facilitation intensity and resilience to better assess the facilitators' affective experiences.[8] They conceptualized facilitation intensity and facilitator resistance by employing an instrumental case study and utilizing facilitator data from the Coordination and Coaching Toolkit (CACT) Initiative. As a result, facilitation intensity was defined as "both the quantitative and/or qualitative measure of the volume of tasks and activities needed to engage and motivate recipients in implementation, and the psychological impact on the facilitator in conducting facilities skills and activities." Facilitator resilience was defined as "the ability to cope with and adapt to the complexities of facilitation to effectively engage and motivate staff while nurturing and sustaining hope, self-efficacy, and adaptive behaviors in oneself."[9]

The researchers highlighted that the facilitators' experiences with the facilitation process varied within the same implementation effort and among different facilitators. One way facilitators can mitigate the effects of high-intensity facilitation is to develop resilience. By supporting facilitator resilience, healthcare organizations can contribute to the sustainability of a skilled facilitator workforce necessary for ongoing practice innovations.

In a separate study, Hunter and colleagues examined the utility of conversation analysis (CA) as an interactional approach to explore facilitation as an implementation intervention.[9] Effective facilitation requires significant interactional and interpersonal skills. The authors explored whether the application of CA could expand the current understanding of facilitation within the implementation science field.

Conversation analysis is a methodological approach that examines how social actions are routinely achieved through developing verbal and non-verbal resources in conversation. A premise of conversational analysis is that conversation is action-oriented and that actions are achieved in a sequential and orderly sequence of conversational turns. The authors provided an example to illustrate how conversational analysis could be used to understand facilitation in practice. A limitation of CA is the requirement to video and audio record interactions for analyses.

Formal facilitation interactions are often complemented by informal, ad-hoc interactions between recipients and facilitators, posing challenges in recording these less-formal interactions. Therefore, the authors proposed using CA as an additional strategy to explore facilitation within the implementation, complementing the current understanding of the facilitation process.

Facilitation programs have demonstrated success in various groups and settings. An example of this is described by Anspach et al, who documented how 3 NPD practitioners empowered a Telemetry Education Nurse Team (TENT) to take the lead and facilitate discussion groups using active educational strategies.[10] The 7-member TENT team included bachelor's prepared nurses who were passionate about education. The 6-month education program focused on 3 key areas. These included a literature review, discussion group facilitation strategies, and practice leading discussion groups. The NPD practitioners provided mentorship to the nurses at each stage of the process, and at least one NPD was present during the discussion group to offer assistance. The TENT nurses reported increased self-confidence due to their facilitation roles, which allowed the NPD practitioners to focus on other priorities.

NPD practitioners are often tasked with facilitating simulation experiences, although they may not possess the necessary skills for this role. LeFond and Blood outlined a curriculum development framework for developing an instructor course specific to NPD practitioners to address this gap. Using Kerns' systematic curriculum development framework, the authors followed 6 steps in the process, which encompassed the following:

1. Identifying the problem and conducting a general needs assessment
2. Conducting a targeted needs assessment
3. Using the findings from the targeted needs assessment to develop goals and objectives.
4. Developing educational strategies
5. Implementing the education
6. Evaluating the program

The instructor course was designed to accommodate 20 clinical nurse educators and clinical nurse specialists. The focused needs assessment included designing simulations for assessment and training purposes, facilitating simulations, facilitating specifics, choosing simulations to fit learning objectives, and evaluating simulations. To determine the course content, LeFond and Blood explored various content sources, including departmental policies for simulation, identified learning needs, current priorities, ongoing projects, and simulation and education literature.[11] Based on the gathered data, they developed a 2-day course comprising a 5-hour session in a computer lab and a 4-hour session dedicated to delivering and debriefing simulations. After completing the course, the participants' confidence level showed improvement across all items on the targeted needs assessment, and overall course evaluations were positive.

When the COVID-19 pandemic emerged in 2020, NPD educators faced the challenge of rapidly adapting their educational approaches to virtual platforms. Reid and colleagues documented their efforts in preparing NPD practitioners for virtual facilitation experiences within a transition-into-practice program spanned 52 hospitals across 5 states.[12] To ensure high-quality online learning experiences, they followed the Quality Matters Higher Education Rubric guidelines, which promote online and blended coursework standards. In response, they created the Facilitate Virtual Clinical Academy Curriculum (FVCAC) course, which uses a virtual delivery platform.

The course included an introductory overview and 5 lessons that could be completed independently and on-demand, requiring approximately 4 hours. The lessons covered topics such as customizing the specialty curriculum, managing the virtual residency, facilitating a virtual synchronous curriculum, addressing challenges in online learning, and concluding a specialty cohort. By creating and implementing a virtual course that provided instructions on this new methodology, NPD practitioners successfully transitioned to virtual education with provided preparation support and mentorship.

Due to the shift to virtual work during the pandemic, researchers also had to adapt their data collection methods, including methods used with focus groups commonly used in qualitative research. Smith and colleagues highlighted the need for increased security and secure methods of collecting data when conducting virtual focus groups. These focus groups can be valuable tools for NPD practitioners to identify knowledge gaps and assess the educational needs of participants. Focus groups generally consist of 4 to 12 members, with 6 being the ideal number to ensure smooth facilitation and data transcription.

Focus groups often include a facilitator, moderator, note-taker, and observer. Several considerations arise when comparing the advantages and disadvantages of in-person and virtual focus groups. The virtual format must ensure the privacy and confidentiality of participants. Platforms that have enhanced security and privacy settings should be used. Videoconferencing platforms should provide features like multiple "rooms" that enable the facilitator to have separate conversations with individual participants, maintaining the integrity of private discussions. Participants should be encouraged to use pseudonyms or anonymous identifiers during the focus group to further protect their privacy and confidentiality.

Facilitating in Various Settings

Facilitation has been used in a variety of settings. Medland and colleagues conducted a study outlining how simulation was employed to improve the knowledge, skills, and abilities of emergency department (ED) staff members regarding patient experience.[13] The study involved a half-day learning forum required for all team members whose roles involved direct contact with ED patients. Approximately 95% of the staff, totaling 115 team members, participated in this education session.

During the forum, participants rotated through 4 skills stations and completed a final simulation designed to apply information from the skills stations to patient interaction. The authors provided detailed information about the setup and structure of the education program, allowing others to replicate it in their settings. 

A study focused on mental health professionals in 9 Veterans Administration (VA) medical centers aimed to explore the perceptions of external facilitators (EF) regarding internal facilitation (IF) during a collaborative care initiative for mental health teams.[14] Facilitation plays a crucial role in promoting the adaptation of innovations by helping individuals and teams understand the change processes and achieve implementation goals. This underpins the need for individuals involved in implementation science to better understand the mechanisms contributing to healthcare innovations' success within organizations. Many initiatives use a blended approach, using EFs to foster facilitation skills development within IFs.

This qualitative research study examined the characteristics of IFs from the perspective of the EFs. Data were collected from a randomized stepped wedge hybrid type II implementation trial that utilized the I-PARIHS framework during the Collaborative Chronic Care Model (CCM) implementation to improve care processes. Semi-structured interviews were conducted with 3 EFs to assess their impressions of IFs' skills and the dynamics between EFs and IFs throughout the process. The I-PARHIS recommendations informed the interview guide.

The EFs identified several essential aspects of IFs' skills. They emphasized the need for IFs to establish appropriate goals, clearly define team member roles, delegate tasks effectively, and maintain frequent follow-up. Furthermore, EFs highlighted the role of IFs as thought leaders and guides who were respected and trusted by the team. Personal characteristics, including emotional intelligence, were identified as key factors contributing to the success of IFs in their facilitation role.

Clinicians play an essential role in advanced care planning (ACP) by initiating discussions and acting as decision coaches. However, their limited involvement in ACP discussions is often attributed to a lack of training. To address this issue, Wing Han Chan and colleagues conducted a systematic review to examine the impact of ACP facilitator training programs. The review included 10 studies, and the findings indicated that training healthcare professionals positively affected their knowledge, attitude, and skills related to ACP.

Facilitation-based factors that increased the efficacy of the training programs included the utilization of decision aids, incorporation of advanced technology into the training, implementing role-play exercises, focusing on communication skills development, and emphasizing the needs and experiences of the patient throughout the ACP process.

Pimentel and colleagues conducted a study focusing on nursing homes, aiming to address the need for improved quality of care. To enhance the implementation of quality improvement projects in nursing homes, the researchers proposed using blended facilitation, which involves external and internal facilitators. This approach fosters a supportive environment for knowledge exchange, identifies implementation barriers, and develops strategies to overcome them.

Blended facilitation involves a 2-way process of building relationships and enhancing skills, thereby creating a supportive environment that facilitates the exchange of knowledge, identifies implementation barriers, and develops strategies to overcome these barriers. To illustrate the concept, the authors presented a real-world example of blended facilitation used in a VHA-funded community living centers (CLC)-based study, Developing and Implementing Resident-centered Efforts in Cultural Transformation (DIRECT).

The study demonstrated that training for healthcare professionals in ACP positively affected their knowledge, attitude, and skills related to ACP.

Clinical Significance

NPD practitioners are critical in implementing research and evidence-based interventions into practice. Implementation facilitation is often used to assist healthcare facilities in implementing evidence-based initiatives. In addition to facilitating the professional growth of nurses and other healthcare professionals, NPD practitioners are champions of scientific inquiry and act as facilitators to help healthcare professionals integrate evidence-based strategies into their practices.

As learning facilitators, NPD practitioners utilize the skills discussed in this article to engage learners in educational activities and adapt their strategies based on learner responses. They use the educational design process to address practice gaps and identified knowledge, skill, and performance needs, aiming to enhance quality and safety and improve health outcomes.

Nursing, Allied Health, and Interprofessional Team Interventions

NPD practitioners collaborate with other healthcare team members to achieve positive health outcomes. Interprofessional teams collaborate to promote health and deliver optimal care. Facilitation skills are an essential component in achieving this goal.