Table 5.

Examples of sequences, cycles, and spirals in the spread process

	Examples
Sequences	In all three spread sites, participants described sequences of the spread process, where certain phases or activities occurred in a sequential order. This is illustrated in the model with the sequential movement from committing to change through to small-scale implementation, adapting locally, spreading internally to more sites and users, and finally disseminating externally.
Cycles	In all three spread sites, participants described cycles of activities, in particular educating the staff about the tool, having the staff try the tool in practice, receiving their feedback about the tool, using that feedback to revise the tool, and then having the staff try out the revised version, and going through the process again. This is illustrated in the model with two-way arrows between the phases of implementing on a small scale and adapting locally, and adapting locally and spreading internally.
Spirals	Participants at the spread sites described ways in which the spread activities gained momentum or accelerated/spiraled over time. This is illustrated in the model with the increasing size of sequential phases (circles) and the increasing size of the spiral rope over the spread phases. Participants explained that the process of implementing on a small scale took longer than later internal spread activities, as this involved more revisions to the tools, and testing of different approaches. At site 1, there was momentum as the tool was incorporated into other practice areas reaching a much larger client population: “We really learned that we could incorporate the pain assessment or management…into other flow sheets, our palliative care flow sheet, our oncology wound, so on. We’ve incorporated pain management more into our wound program which spans 60% of our clients…so it has definitely spiraled into a much bigger population than just…pain management.”