'Having a say': negotiation in fourth-generation evaluation

Practical way to apply fourth-generation assessment tools integrated into creating meaningful learning experiences in biology at high school

The learning process for a Biology topic regarding organisms and animal kingdom diversity was investigated through an innovative Interactive Didactic Sequence (IDS) which integrated the idea of "concept maps" with the Hermeneutic-Dialectic Circle (HDC). HDC is a tool for data collection and a reference for pluralist-constructivist thinking, considered a form of fourth-generation evaluation. Hofstede's cultural dimensions were also integrated into the investigation in order to facilitate mediation in an evaluative context. Students' performances (N = 25) from a São Paulo-Brazil public school were statistically evaluated. Their cultural profile was determined via the Hofstede Value Survey Model 1994 questionnaire. The elaborative process of arranging concept maps was individual (CM-individual) and integrated with HDC in groups (CM-HDC). Concept map assessment methods were based off existing literature. An improvement in students' performances (p < 0.05) that presented concept maps integrated to HDC in a more complex structure when compared to individually-built maps was observed. Employment of HDC helped form motivational/interactive dialogues between students and teachers, which, in turn, assisted in achieving greater learning through the use of concept maps. The application of the fourth-generation evaluation was improved via knowledge regarding students' cultural profiles.

Two Women with Multiple Sclerosis and Their Caregivers: conflicting normative expectations

It is not uncommon that nurses are unable to meet the normative expectations of chronically ill patients. The purpose of this article is to describe and illustrate Walker’s expressive-collaborative view of morality to interpret the normative expectations of two women with multiple sclerosis. Both women present themselves as autonomous persons who make their own choices, but who also have to rely on others for many aspects of their lives, for example, to find a new balance between work and social contacts or to find work. We show that their narratives of identity, relationship and value differ from the narratives that others use to understand and identify them. Since identities, relationships and values give rise to normative expectations, in both cases there is a conflict between what the women expect of their caregivers and vice-versa. The narratives also show that two similar persons with multiple sclerosis may need very different care. This implies that nurses caring for such persons should listen carefully to their stories and reflect on their own perceptions of self.

Non-medical prescribing of chemotherapy: engaging stakeholders to maximise success?

AIM

This study report examines the views and experiences of professional stakeholders about non-medical prescribing (NMP) of chemotherapy.

BACKGROUND

The introduction of open formulary NMP has created opportunities to radically change health-care delivery. For chemotherapy services, the most recent advice from the National Chemotherapy Advisory Group [Department of Health (2009) Chemotherapy Services in England, ensuring quality and safety: a report from the National Chemotherapy Advisory Group, London Her Majesty's Stationary Office] clearly endorses the development of nurse- or pharmacist-led chemotherapy clinics. This is very much welcomed but is based on very limited evidence as to their effectiveness.

DESIGN

A fourth-generation evaluation study.

METHODS

A purposeful sample of 23 stakeholders connected with the chemotherapy service was used. A serial data collection technique with individual interviews followed by uni-professional focus groups was adopted. Finally, a multi-professional focus group was held to determine the strategic way forward. Data were collected in 2009-2010.

RESULTS

The study illuminated the key features necessary to maximise success of NMP in chemotherapy clinics and captures the importance of good working relationships. Whilst different practice models will emerge, fundamental and core to services is the need for good team working, established and effective communication strategies, and most importantly avoiding isolation in practice. This study additionally reinforced any evaluation takes place within preexisting political contexts and in particular medical dominance. Not all medical colleagues agreed with or wanted NMP for their patients, highlighting difficulties of developing new models of working within a resisting culture.

CONCLUSION

No objections to NMP of chemotherapy were found, but, clearly, the context of practice needs to be agreed and supportedby all professional stakeholders. What is already known about this topicOpen formulary non-medical prescribing has been rapidly introduced over the past decade.Little research has been conducted in acute care and none in the chemotherapy setting.Cancer policy recommends the introduction of nurse-led chemotherapy clinics.What this paper addsNon-medical prescribing (NMP) in chemotherapy is appropriate with the right model of practice.Well-established professional relationships are a key to success.NMP is not appropriate in isolation of the multidisciplinary team (MDT).Implications for practice and/or policyNurses need to demonstrate the value of non-medical prescribing in chemotherapy using available metrics.Models of practice need to ensure good communication channels, MDT working, and transparency of prescribing.

Perception of quality of care among residents of public nursing-homes in Spain: a grounded theory study

Background

The quality of care in nursing homes is weakly defined, and has traditionally focused on quantify nursing homes outputs and on comparison of nursing homes’ resources. Rarely the point of view of clients has been taken into account. The aim of this study was to ascertain what means “quality of care” for residents of nursing homes.

Methods

Grounded theory was used to design and analyze a qualitative study based on in-depth interviews with a theoretical sampling including 20 persons aged over 65 years with no cognitive impairment and eight proxy informants of residents with cognitive impairment, institutionalized at a public nursing home in Spain.

Results

Our analysis revealed that participants perceived the quality of care in two ways, as aspects related to the persons providing care and as institutional aspects of the care’s process. All participants agreed that aspects related to the persons providing care was a pillar of quality, something that, in turn, embodied a series of emotional and technical professional competences. Regarding the institutional aspects of the care’s process, participants laid emphasis on round-the-clock access to health care services and on professional’s job stability.

Conclusions

This paper includes perspectives of the nursing homes residents, which are largely absent. Incorporating residents’ standpoints as a complement to traditional institutional criteria would furnish health providers and funding agencies with key information when it came to designing action plans and interventions aimed at achieving excellence in health care.

Relational responsibilities in responsive evaluation

This article explores how we can enhance our understanding of the moral responsibilities in daily, plural practices of responsive evaluation. It introduces an interpretive framework for understanding the moral aspects of evaluation practice. The framework supports responsive evaluators to better understand and handle their moral responsibilities. A case is introduced to illustrate our argument. Responsive evaluation contributes to the design and implementation of policy by working with stakeholders and coordinating the evaluation process as a relationally responsible practice. Responsive evaluation entails a democratic process in which the evaluator fosters and enters a partnership with stakeholders. The responsibilities of an evaluator generally involve issues such as 'confidentiality', 'accountability' and 'privacy'. The responsive evaluator has specific responsibilities, for example to include stakeholders and vulnerable groups and to foster an ongoing dialogue. In addition, responsive evaluation involves a relational responsibility, which becomes present in daily situations in which stakeholders express expectations and voice demands. In our everyday work as evaluators, it is difficult to respond to all these demands at the same time. In addition, this article demonstrates that novice evaluators experience challenges concerning over- and underidenfitication with stakeholders. Guidelines and quality criteria on how to act are helpful, but need interpretation and application to the unique situation at hand.

Collaboration and co-ownership in research: dynamics and dialogues between patient research partners and professional researchers in a research team

BACKGROUND

  Different strategies by which patients can be involved in research include consultation, control and collaboration. This article focuses on collaboration within research teams and considers this with reference to a research project about setting a social-scientific agenda for health research from the perspectives of patients with a chronic kidney disease (CKD).

OBJECTIVE

  To examine the dynamics and dialogues in a collaboration between patient research partners and professional researchers.

DESIGN

  A responsive methodology was used in the research project. Two patient research partners participated in the research team. Twenty-seven patients with CKD and parents of young children with CKD were interviewed, seven focus groups were organized and observations were held at a dialysis centre.

RESULTS

  During the collaboration, the research partners and professional researchers engaged in a mutual learning process in all stages of the project. The professional researchers gave the research partners a sense of ownership in the research process. The research partners could relate to the lives of patients by using their experiential knowledge. In the context of collaborative working, this helped shape an agenda for research.

CONCLUSION AND DISCUSSION

  The active involvement of patients as research partners can add value to a research strategy, especially when research partners and professional researchers engage in a dialogue that is open, inclusive and deliberative. Issues for discussion include the possibility of 'over-involvement', the research profile and training of research partners and whether participation of patients is restricted to certain types of research.

Collaboration and co-ownership in research: dynamics and dialogues between patient research partners and professional researchers in a research team

BACKGROUND

  Different strategies by which patients can be involved in research include consultation, control and collaboration. This article focuses on collaboration within research teams and considers this with reference to a research project about setting a social-scientific agenda for health research from the perspectives of patients with a chronic kidney disease (CKD).

OBJECTIVE

  To examine the dynamics and dialogues in a collaboration between patient research partners and professional researchers.

DESIGN

  A responsive methodology was used in the research project. Two patient research partners participated in the research team. Twenty-seven patients with CKD and parents of young children with CKD were interviewed, seven focus groups were organized and observations were held at a dialysis centre.

RESULTS

  During the collaboration, the research partners and professional researchers engaged in a mutual learning process in all stages of the project. The professional researchers gave the research partners a sense of ownership in the research process. The research partners could relate to the lives of patients by using their experiential knowledge. In the context of collaborative working, this helped shape an agenda for research.

CONCLUSION AND DISCUSSION

  The active involvement of patients as research partners can add value to a research strategy, especially when research partners and professional researchers engage in a dialogue that is open, inclusive and deliberative. Issues for discussion include the possibility of 'over-involvement', the research profile and training of research partners and whether participation of patients is restricted to certain types of research.

Participation of marginalized groups in evaluation: mission impossible?

Responsive evaluation facilitates a dialogical process by creating social conditions that enhance equal input from all stakeholders. However, when multiple stakeholders are involved, some groups tend to go unheard or not be taken seriously. In these cases, empowerment of the more silent voices is needed. The inclusion of marginalized groups in evaluation is thus a challenge for evaluators. It raises questions about how to include all stakeholders in the evaluation process in a way that empowers marginalized stakeholder groups, and at the same time is acceptable for the dominant stakeholder groups. In this article we describe our experiences with a responsive evaluation project on the participation of client councils in policy processes in a Dutch residential care and nursing home organization. We focus on the value of hermeneutic dialogue (fostering mutual understanding and learning processes) in addressing the challenges of working with stakeholders in unequal relationships.

Good care in ongoing dialogue. Improving the quality of care through moral deliberation and responsive evaluation

Recently, moral deliberation within care institutions is gaining more attention in medical ethics. Ongoing dialogues about ethical issues are considered as a vehicle for quality improvement of health care practices. The rise of ethical conversation methods can be understood against the broader development within medical ethics in which interaction and dialogue are seen as alternatives for both theoretical or individual reflection on ethical questions. In other disciplines, intersubjectivity is also seen as a way to handle practical problems, and methodologies have emerged to deal with dynamic processes of practice improvement. An example is responsive evaluation. In this article we investigate the relationship between moral deliberation and responsive evaluation, describe their common basis in dialogical ethics and pragmatic hermeneutics, and explore the relevance of both for improving the quality of care. The synergy between the approaches is illustrated by a case example in which both play a distinct and complementary role. It concerns the implementation of quality criteria for coercion in Dutch psychiatry.

A cooperative inquiry into action learning and praxis development in a community nursing module

As nurse lecturers we investigated practice development and action learning approaches aimed at enabling postregistration bachelor's- and master's-level nursing students (Community Health Studies, Nursing in the Home) to advance practice in the context of policy and professional developments. A patchwork text was used to assess summatively what students achieved (practice change/development) and how this was informed critically, via an extended epistemology. First-person inquiry supplemented by cooperative inquiry postcourse completion (including reflective discussions with 16 students and 16 practice mentors) were used to assist coresearcher constructions of meaning. A relational, tripartite approach to learning and assessment (students', teachers', and practice mentors' collective contributions) depends on continuing reflective attention. Action learning enhances interrelation of experience with dialectic thinking. The patchwork text functions to promote creative writing, evaluative thinking, and praxis development. Role modeling by all, being genuine and not just "talking" genuine, is challenging yet crucial if people are to function as mutual resources for learning.

Dialogical Nursing Ethics: the Quality of Freedom Restrictions

This article deals with the question of how ethicists respond to practical moral problems emerging in health care practices. Do they remain distanced, taking on the role of an expert, or do they become engaged with nurses and other participants in practice and jointly develop contextualized insights about good care? A basic assumption of dialogical ethics entails that the definition of good care and what it means to be a good nurse is a collaborative product of ongoing dialogues among various stakeholders engaged in the practice. This article discusses the value of a dialogical approach to ethics by drawing on the work of various nursing scholars. We present a case example concerning the quality of freedom restrictions for intellectually disabled people. Issues for discussion include the role and required competences of the ethicist and dealing with asymmetrical relationships between stakeholders.

Implementing moral case deliberation in a psychiatric hospital: process and outcome

BACKGROUND

Clinical moral case deliberation consists of the systematic reflection on a concrete moral case by health care professionals. This paper presents the study of a 4-year moral deliberation project.

OBJECTIVES

The objectives of this paper are to: (a) describe the practice and the theoretical background of moral deliberation, (b) describe the moral deliberation project, (c) present the outcomes of the evaluation of the moral case deliberation sessions, and (d) present the implementation process.

METHODS

The implementation process is both monitored and supported by an interactive responsive evaluation design with: (a) in-depth interviews, (b) Maastricht evaluation questionnaires, (c) evaluation survey, and (d) ethnographic participant observation. In accordance with the theory of responsive evaluation, researchers acted both as evaluators and moderators (i.e. ethicists).

RESULTS

Both qualitative and quantitative results showed that the moral case deliberations, the role of the ethics facilitator, and the train-the-facilitator program were regarded as useful and were evaluated as (very) positive. Health care professionals reported that they improved their moral competencies (i.e. knowledge, attitude and skills). However, the new trained facilitators lacked a clear organisational structure and felt overburdened with the implementation process. The paper ends with both practical and research suggestions for future moral deliberation projects.

Using enquiry in learning: from vision to reality in higher education

This paper reports on the contribution of six nurse educators to embed enquiry-led learning in a pre-registration nursing programme. Their focus was to evaluate student and facilitator perspectives of a hybrid model of problem-based learning, a form of enquiry-based learning and to focus on facilitators' perceptions of its longer-term utility with large student groups. Problem-based learning is an established learning strategy in healthcare internationally; however, insufficient evidence of its effectiveness with large groups of pre-registration students exists. Fourth Generation Evaluation was used, applying the Nominal Group Technique and Focus Group interviews, for data collection. In total, four groups representing different branches of pre-registration students (n = 121) and 15 facilitators participated. Students identified seven strengths and six areas for development related to problem-based learning. Equally, analysis of facilitators' discussions revealed several themes related to strengths and challenges. The consensus was that using enquiry aided the development of independent learning and encouraged deeper exploration of nursing and allied subject material. However, problems and frustrations were identified in relation to large numbers of groups, group dynamics, room and library resources and personal development. The implications of these findings for longer-term utility with large student groups are discussed.

Critical realism as emancipatory action: the case for realistic evaluation in practice development

To provide rigour when preparing a research design, the researcher needs to carefully consider not only the methodology but also the philosophical intent of the study. This, however, is often absent from reported research and provides the reader with little evidence by which to judge the merits of the chosen methodology and its influence on the study. The purpose of this paper is to set out the case for critical realism as a framework to guide appropriate action in practice development and realistic evaluation for understanding the consequences of those actions. It is evident that critical realism and critical social science share common ground. Emancipatory practice development (ePD) is based on the philosophy of critical social science and therefore by virtue is linked to the tenets of critical realism. Until now, the evaluation of ePD programme has been well served by 4th-generation evaluation. However, this paper outlines the need for a different approach to evaluation, one that is based on critical realism, that is concerned with emancipation, and that can be used in the ever-changing environment of clinical practice. Realistic evaluation not only links strongly to ePD programmes, but also serves as the basis for effective research questions that will test the outcomes of the research and inform the transferability of ePD mechanisms into differing contexts.

Patient participation in health research: research with and for people with spinal cord injuries

Traditionally, patients are rarely seen as partners in health research; their influence on priority setting, research design, the undertaking of research, and interpretation and dissemination of findings was marginal. Nowadays, health researchers, funding agencies, governments, and patient organizations are beginning to acknowledge that the passive role of patients in health research is no longer satisfactory. The emerging commitment and consensus concerning the aims and features of patient participation in research have created a need for an appropriate method to engage patients as partners in health research. In this article, the author argues that a responsive-constructivist approach to evaluation fits with the aims and features of patient participation. She illustrates its potential with a case example that concerns a dialogue among patients and (clinical) researchers in the field of spinal cord injuries. She reflects on learning experiences and the (un)expected difficulties and potentials in creating social conditions for patient participation in health research.

Responsive evaluation in health promotion: its value for ambiguous contexts

Responsive evaluation offers a perspective in which evaluation is reframed from the assessment of program interventions on the basis of policymakers' goals to an engagement with all stakeholders about the value and meaning of their practice. This article argues for this perspective both generally and more particularly in relation to health promotion. Responsive evaluation is especially appropriate in health promotion contexts characterized by a high degree of ambiguity. Ambiguity refers to the absence of or contradictory interpretations about what needs to, can and should be done, when and where. Ambiguity is high in the case of non-routine programs, lack of knowledge about success indicators, collaborative and community based programs and the absence of consensus among stakeholders. In health promotion contexts marked by a low degree of ambiguity random controlled trials (RCTs) and quantitative methods are to be considered. This implies the evaluators should assess the degree of ambiguity of a situation before deciding about an appropriate design.

Giving people a voice: reflections on conducting interviews with participants experiencing communication impairment

AIM

The aim of this paper is to describe the various strategies employed to mitigate communication impairments and to argue that illness experiences may be captured through methods other than audio-tape recordings of spoken words.

BACKGROUND

This paper explores issues surrounding the collection of interview data from participants experiencing communication impairments. It derives from a qualitative interview study, which enquired into experiences of living with a percutaneous endoscopic gastrostomy. This is an artificial route created directly into the stomach for long-term delivery of nutrition to people who are unable to take nutrition via the normal route. However, in many cases the physical impairments that led to their requirement for this form of feeding also made speech, and hence interviewing, very difficult.

DISCUSSION

Capturing illness experiences from participants with impaired communication requires a reconsideration of both practical strategies and broader methodological issues. In addition to the adaptation of data generation strategies a re-examination of the complexities inherent in the meaning of 'patient experience' is required. This paper explores the utility of verbal and other interactional input from carers to explore further dimensions of this experience.

CONCLUSION

Qualitative research that seeks to capture the meanings of illness from the patient's perspective needs to be adapted to embrace different modes of communicating the illness experience.

Sharing stories: narrative and dialogue in responsive nursing evaluation

Responsive evaluation is an emerging vision and rationale for nursing evaluation. In this vision, evaluation is redefined as an engagement with all stakeholders about the value and meaning of their practice as a vehicle for learning, understanding, and improvement. In this article, the authors aim to illustrate the utility of a particular version of responsive evaluation, one that is connected with recent ideas about narrative and dialogue. They concentrate on methodological issues and use a case example to illustrate these issues. The case concerns a responsive evaluation of the quality of palliative care for cancer patients in a Dutch region. Methodological issues include the collection of stories through the use of conversational interviews. Stories can reveal the meaning and ambiguity of everyday situations. If evaluators listen to different stories and facilitate a dialogue about stories, this will enhance mutual understandings and promote respect, inclusiveness, and social equity.

Nurse-managed clinics: issues in evaluation

BACKGROUND

Nurse-managed clinics (NMCs) have been in existence for over 30 years. Evaluation of such clinics has been sparse and most have used entirely quantitative techniques. This article explores the importance of evaluation of NMCs using the Mana Health Clinic in Auckland, New Zealand as an example.

DISCUSSION

Fourth generation evaluation is offered as an appropriate methodology for undertaking evaluation of NMCs. Fourth generation evaluation actively seeks involvement of clients in the process and outcome of the evaluation, resulting in participation and empowerment of stakeholders in the service - a precept often forgotten in traditional evaluation strategies and of vital importance in understanding why people use NMCs. The method proposed here also incorporates the need for quantitative data.

CONCLUSION

The main argument proposed here is that a combination of qualitative and quantitative data sources is likely to give the greatest understanding of NMCs utilization. Evaluation of NMCs is vital to the continuation of this type of health service. However, evaluation must be appropriate to the service being studied. Fourth generation evaluation used to elicit client's perceptions of the clinic along with quantitative data is offered as an appropriate means of achieving this.

Journeying from the philosophical contemplation of constructivism to the methodological pragmatics of health services research

AIM

This paper presents our journey through a contemplation of the philosophical origins of constructivism to consider its role as an active methodology in qualitative research.

METHOD

The first part of the paper summarizes the philosophical background of constructivism and the five principles underpinning this paradigm as described through the works of Guba and Lincoln. The philosophical roots of constructivism are then compared with postpositivism, critical realism and participatory inquiry. The paper moves on to consider their common methodological steps, before examining how the constructivist research strategy is being adopted and adapted within the pragmatics of health service research. Recent studies will be drawn upon to illustrate the use of constructivist methodology.

CONCLUSION

Questions are raised about the role of philosophy and the extent to which it should or does underpin or influence qualitative research strategies. We believe that if researchers gain an understanding of both philosophy and methodology a richer and more robust study is likely to result.

Synergy towards health: a nursing intervention model for women living with fibromyalgia, and their spouses

AIM

The purpose of this study was to develop a consensus-based nursing intervention model for women living with fibromyalgia, their spouses and nurses working in a community health centre in Québec, Canada.

BACKGROUND

Fibromyalgia syndrome, a rheumatic disorder associated with severe chronic pain and fatigue, has a major impact on the lives of individuals and their family. To date, research results on effective interventions are somewhat limited and inconclusive. Few studies take into account the perspective of those who live with this health problem on a day-to-day basis.

METHODS

Data were collected mainly in 1999, through in-depth interviews and through group meetings using a qualitative research design, along the lines of the constructivist paradigm. The analysis plan aims for movement between the global and the specific: synthesis and thematic analysis. Analysed data were submitted to all participants throughout the data-collection process, thus allowing for shared constructions.

FINDINGS

Results present the general consensus stemming from shared construction in all three groups. The nature of the intervention involves two major elements, support and teaching along with the fundamental importance of believing in the person. The timing of the intervention and the health and social context in which the intervention occurs also emerge as integral parts of the model. Synergy towards health in fibromyalgia emerges as the constitutive pattern composed of the following three elements: personal growth, spousal and professional support. The discussion addresses the model's components and uses an ecological perspective, in order to consider all the contexts that greatly influence the intervention. Empowerment is embedded in this intervention model.

CONCLUSIONS

This study shows that research based on partnership allows the integration of perspectives and skills of various actors so as to develop meaningful interventions for both those seeking care and health professionals.

Chronic illness: reflections on a community-based action research programme

AIM

The purpose of this paper is to describe the birth of a research culture in a community nursing service, and the development and implementation of an action research programme that focuses on understanding the experiences of living with chronic illness.

BACKGROUND

Approximately 70% of the clients of our community nursing practice in South Australia live with chronic illness. Our research interest has focused on how community nurses can assist people living with chronic conditions to live 'well'. In this paper we describe the way in which we have applied the principles of participatory action research (PAR) when working with women who live with multiple sclerosis (MS) and urinary incontinence. We then draw on elements of PAR research with men who live with MS and men and women who live with type 2 diabetes. In total, we have convened eight PAR groups researching with people who live in the community with chronic illness and this work constitutes our chronic illness research programme.

DESIGN

The PAR philosophy is based on the principles of democratic, equitable, liberating and life enhancing relations within a research process, and is operationalized in cycles of: look, think and act. In these collaborative inquiries the researchers have facilitated participants to reflect on how illness affects their lives, to tell their own story, make connections, plan action and help them negotiate the rites of passage. We select two areas for discussion: methodological issues in the application of PAR principles and our tentative findings from the chronic illness research programme.

FINDINGS

We assert that the facilitator's skill in managing group dynamics is crucial to the life and outcome of the project. Change can occur as a result of action at an individual level, with improved self-management of chronic illness, or at a collective level where the PAR group instigates larger reform strategies. In terms of tentative findings, men and women living with a chronic illness appear to be involved in an ongoing process of transition toward incorporating the illness into their lives. Although we have not yet identified specific events, we have noted that there are critical turning points in the illness transition experience. Participants feel validated in telling their story of living with a chronic illness. Story telling may be the turning point that enhances the lives of all those who participate.

CONCLUSION

If health care professionals can understand the process that facilitates people to move toward incorporating chronic illness into their lives, we can make a substantial contribution to enhance their chronic disease self care management.

Evaluating a community nursing service: listening to the voices of clients with an intellectual disability and/or their proxies

The aim of this study was to evaluate a specialist nursing service programme for people with an intellectual disability residing in the community. It is important to correct the imbalance in the literature that has neglected the voices of the clients themselves or denied expression by their proxies. The aim of the study was to gain a better understanding of matters of importance for clients and their families and to involve them in the evaluation of a service that directly affects their care. Only three clients were able to participate; however, 17 parents (next of kin) agreed to be interviewed. In-depth interviews were audio-taped, transcribed and analysed relating to the questions asked and were checked against the domains of the nursing practice in the disability area: continuity of care, advanced nursing practice, education and credentialling, personal and professional attributes, primary health care, and normalization. The findings confirm the high regard in which the programme is held. Service evaluation is crucial in providing evidence for programme funders. The favourable outcome of this evaluation meant that the programme gained funding for another few years.