Make or break: factors influencing the development of nursing practice within the UK National Health Service.

The development of nursing practice has become a central feature of modern healthcare. The advent of clinical governance has resulted in the development of an organisational climate where practitioners are encouraged to develop direct care and health services. Despite the desire of many professional groups to develop practice within the NHS, there has been a shortage of research which has specifically examined the processes of practice development in such a way as to identify the factors which facilitate or hinder developments. This study examines the nature of practice development and how this process is influenced by organisational, structural, individual and contextual factors. Using techniques developed by Walker and Avant (1995), the critical attributes of practice development were identified and it was contended and accepted that practice development was a specialist form of innovation. The study identified positive and negative factors which were shown to influence practice development using two principal methodologies. Firstly, a UK-wide Delphi survey was carried out with 139 Directors of Nursing in order to identify their perceptions of key influences on practice development. A total of 24 positive and 23 negative categorisations was identified from the surveys; these were grouped using principal component analysis into 8 components. Following on from this a series of case studies was carried out to examine which factors influenced the development of practice, and how this influence manifested itself. Findings from the case studies highlighted that there was some congruence between the perceptions of Directors of Nursing and the factors which were found to influence development. Several factors were identified as having a positive influence including championship, participation, ownership and flat management structures; whereas factors such as leader dependence, pressures and inter-professional tensions had a negative influence in some developments. In addition the study identified that the influence of other factors such as personal interest, merger and organisational transition are often underestimated