CHAPTER 5

Application of Professional Practice Models: Implementation

KEY WORDS

Implementation plan, implementation strategies

OBJECTIVES

By the end of this chapter, readers will be able to:

1.  Describe the components of a professional practice model (PPM) implementation plan

2.  Recognize the difference between goals and objectives

3.  State measurable goals

4.  Choose implementation strategies that align with nursing values and organizational strengths

5.  Enrich the implementation plan by including encouraging behaviors and reinforcement techniques

THE IMPLEMENTATION PLAN

Once the “thinking” work of designing a professional practice model (PPM) has been completed, it is appropriate to begin acting. In this case, action refers to initiating the phases of integration (see Figure 2.1) by defining the work that is to be done (planning), designing evidence-based strategies (generating), and assigning appropriate responsibilities and time frames for completion (accountability). In this chapter, focus will be placed on implementing the application phase. Although this sounds like a simple task, implementation plans frequently fail “not because the new strategies or goals are inappropriate but rather because organizations are unable to successfully implement them” (Caldwell, Chatman, O’Reilly, Ormiston, & Lapiz, 2008, p. 125).

PLANNING

When approached with discipline and full participation, planning, generating, and establishing accountability for implementation involves the following: establishing a committee; emphasizing the certainty of the PPM; reflecting on the position of the organization relative to the PPM; setting strategic goals; creating action-oriented objectives (in measurable terms); selecting evidence-based implementation strategies to meet specific objectives; building in ongoing support and enrichment activities; prioritizing strategies; and assigning responsibility and expectations for completion (Figure 5.1).

Step 1 includes establishing a diverse committee that includes representatives from all nursing levels. The membership of the implementation committee should include key nursing staff leaders (e.g., the chairs of nursing councils, especially the practice council) in order to take advantage of their experience and expertise and enlist their help in implementing the plans they helped shape. For example, those champions of the PPM (e.g., those who best defended its concepts and advocated for its adoption) would be ideal committee members. In addition, the committee should comprise selected members of nursing administration, nursing education, advanced practitioners, and others who can offer important insights and support to this group. The final implementation committee membership ideally should be around eight to 15 members (depending on the size of the health system).

The implementation committee elects a leader or facilitator, establishes a routine meeting schedule with rules regarding participation and processes, and forms communication and feedback processes. Developing a realistic timeline for completion of a PPM implementation plan and sticking to it will expedite the committee’s progress. Keeping the focus on those forces impacting future nursing practice as well as incorporating best evidence into the implementation will inform the quality of the result.

Figure 5.1 Implementation process.

Step 2 involves committee members’ strong and continuing support of those convictions that formed the basis for the newly designed PPM, being careful to tie the model to the organizational mission and nursing values statements. Feedback from patients and families and administration concerning the value of the model extends its validity, strengthening buy-in. Such endorsement reinforces the shared vision for nursing practice, ensures that the beliefs and values of nursing are respected and upheld, and helps commit resources to the integration process.

Step 3 involves reflecting back on the internal organizational readiness evidence, particularly the gap analysis (see Chapter 2), and completing a quick strengths, weaknesses, and opportunities/threats (SWOT) analysis (Andrews, 1971) to identify the relative position of the organization (specifically nursing) related to the PPM, the customer (patients, families, health care providers, suppliers, the community, others), the discipline, and other competitors. Involving diverse points of view in the SWOT analysis expands perspectives, thereby improving the possibility of gaining enough knowledge of current nursing practice and its effectiveness. In fact, including patients, families, and others into the SWOT process leverages the analysis even further. Individuals on the implementation committee or small groups working together can participate in collecting SWOT information.

In a SWOT analysis, strengths refer to those nursing attributes or activities that the health system does better than most, or better than anyone else, in the competitive area. Pertinent responses are elicited by asking questions, such as, What do we do well (vis-à-vis professional practice)? Or, What do we do better than most? Reflecting on aspects of practice—such as quality of services; resources spent; application of skills, including technology, innovative solutions applied, professional development, and providing optimal patient experiences—allows for more in-depth analysis. Following are some examples of nursing strengths:

Weaknesses include those attributes and activities that, if substantially improved, would provide nursing with additional probabilities for success. Receiving multiple views from key nurses; leaders within the organization; as well as patients, families, and those outside the organization, ensures that all key weaknesses are identified. Pertinent questions to ask include What do we do not so well (vis-à-vis professional practice)? What should be improved? Are there mistakes we need to avoid? Do others (both within and outside the system) see nursing weaknesses as we do, or differently? Honest and realistic evaluation of nursing practice is essential. Following are some examples of nursing practice weaknesses:

Opportunities are often the product of trends or conditions appearing outside of the organization but within nursing. Some examples are consolidation of services (such as merging inpatient and outpatient services for a population), acquisition of additional health systems, translating new evidence into practice (e.g., transition programs), innovative clinical advancement systems, novel ways of staffing or use of resources, or authentic educational resources (e.g., a university close by).

Following are examples of nursing opportunities:

Threats are the obstacles nursing faces or will face in trying to implement the newly developed PPM. Threats may include lack of resources, poor leadership, negative views of nursing’s role in the system, and lack of needed technology.

Following are some examples of threats:

A thorough SWOT analysis, with full participation of all members of the implementation committee and across key constituencies, sets up the foundation for informed implementation approaches.

The next step includes thorough goal setting, beginning with a series of statements that describe the desired nursing practice in a specified number of years (e.g., 3, 5, 10 years from the present). The length of time to the desired nursing practice is determined by the implementation committee.

Goals are broad targets or intentions that are proposed to describe the desired end state—in this case, the fully integrated PPM. Setting goals inspires success and provides documentation for celebrating accomplishments. As such they should be agreed on and be significant even beyond the specific health system. Goals might cover a variety of categories, and are then stated as follows (in declarative statements):

Once broad goals have been specified, the implementation committee might look back at the SWOT results and recommend modifications of the goals (based on available strengths or to augment noted weaknesses). This might mean identifying potential new goals or suggesting changes in emphasis in order to pave the way for the more specific objective setting.

Developing objectives that relate to each goal requires recognition of the distinction between goals and objectives.

Using the SMART language as an example, objectives should be specific, measurable, achievable, realistic, and timely (Doran, 1981). Specificity refers to understanding (i.e., clear and free of jargon); the terms used are well defined, the actions are focused, and there is enough detail that those involved know what to do. Avoiding words that have vague meanings and using action verbs, such as design, develop, build, and conduct, assists in knowing what to do. Naming those involved (who), including when the activity is to be completed and addressing how exactly the action will be completed, is important. Finally each objective should be neatly aligned with a goal or goals and then again with the overarching PPM. This answers the question, “Why is it important to do this?

Measurable objectives provide a reference point from which changes in goals can be clearly measured. Asking the questions: How will I know when this objective has been achieved? Are there any existing measurements (questionnaires, observations) that I can use to evaluate its completion? and What milestones can I use to track progress toward completion that will ensure a quality objective? It is impossible to determine whether objectives have been met unless they can be measured; thus it is crucial to perform this task correctly. Writing objectives this way does not come easy and takes experience—consulting with an educator or researcher may be helpful.

In the SMART example, achievable is linked to measurable, but refers more to the practicality of attainment. If others have done something successfully, or if members of the planning team have positive experiences with an objective, then it is more likely to be successful. Realistic objectives are those that can be achieved with the available resources (skills, funding, equipment, time, staff) or at least there is a reasonable chance of meeting them. Finally, timing of objectives, particularly identifying the point in time that attainment is expected, enables efficiency of implementation. Example objectives written in response to a set goal are listed as follows:

Building in objectives for monitoring and modifying strategies based on changes in the external environment or the organization is crucial. For example, objectives for taking advantage of unexpected changes, such as more engaged or new top leadership, reductions in dedicated resources, or changes in patient or staff characteristics, should be anticipated and designed into the implementation process. From the specific objectives, the committee can proceed to select those specific strategies that will be used to meet the objectives and overall goals.

IMPLEMENTATION STRATEGIES

Changing behaviors and ways of thinking on a systematic level requires varied evidence-based strategies such as learning opportunities, the alignment of roles and responsibilities, reinforcement activities, redesigning workflow (if necessary), effective communication, and ongoing support and advancement strategies. There is no one set of strategies that fits a particular health system. Rather, based on the initial readiness assessment, SWOT analysis, the stated objectives and PPM itself, organizational priorities, and the evidence base, a set of strategies is selected that best fits the health systems and its employees. After initial development of selected strategies, a review of the implementation goals and objectives may require the implementation committee to recommend alternative approaches or methods to achieve the stated objectives. To begin Step 6, ask questions from the perspective of the patient/family such as:

Or, ask from the perspective of the discipline of nursing:

A disciplined approach should be undertaken to answer these questions and identify those strategies that are evidence based and will lead to successful results (effectiveness) while preserving efficiency. For example, to address learning needs of employees, a face-to-face classroom approach as well as several online modular methods or a combination strategy as suggested by best evidence may be recommended. Based on the unique organization (personnel, resources, etc.) and the needs of its employees for integrating a PPM, decisions can be made using several different approaches (e.g., group consensus, democratic voting). Whatever the specific approach applied, specific criteria for evaluating and choosing among many possible strategies should be agreed on (see Table 5.1). Based on these or other agreed-upon criteria, strategies can be evaluated, chosen, re-evaluated, and finally selected for implementation.

Some systems prefer to engage consultants with expertise in PPM implementation to assist with strategy formulation and integration procedures. Others do it alone. Regardless of the approach, it is crucial to consider multiple evidence-based options and use those experts with considerable experience in implementing new programs. Choosing strategies involves careful consideration of who in the organization (or resources outside the organization that are made available) have the expertise to successfully implement the action. For example, if an implementation goal is to deliver care consistent with a specific nursing theory, then a key strategy might be to increase knowledge of the theory or to revise current job descriptions to support consistency between nursing actions and the theory. After acquiring knowledge of the theory or seeking guidance on nursing job descriptions through reading the literature and/or consultation with the theorist, specified individuals within the organization may take on the responsibility for implementing this strategy.

Table 5.1 Criteria for Selecting Implementation Strategies

Some (but certainly not all) strategies that might be used when implementing a PPM are discussed in the following sections.

Education

Data indicate that providing education and training to individual health care personnel is not enough to change practice. In particular, didactic education used alone has been shown to be less effective than interactive learning opportunities (Bluestone et al., 2013). Yet, many who implement new PPMs develop traditional instructional programs as the only means to change behavior. Some of these are as little as one 2-hour classroom session.

To begin, it is helpful to assess the educational levels and best learning techniques of current employees. Using this information, designing an experiential approach to education, using effective interactive learning techniques, such as case studies, games, point-of-care learning (e.g., clinical rounds), problem-based learning activities, role playing, peer learning, focused assignments, group simulations, and others, is more useful than the passive transfer of information used in traditional classrooms. For example, from a case study used to set up a clinical situation, learners could use the selected nursing theory to develop the plan of care. Or, using another clinical situation, learners could assume roles (assigned by the educator) to perform their respective duties according to a revised nursing job description. These forms of learning tend to “stick” with learners and address both the cognitive and psychomotor requirements of learning. To effectively attend to the affective learning dimension, helping learners perceive the patient’s view is crucial. For example, listening to patient stories, patient participation in the classroom, individual written and group reflections, and working through ethical dilemmas help to instill values and attitudes that are aligned with the chosen PPM.

Most important, research consistently supports that students learn better when they are engaged in the process (Meeks, Heit, & Page, 2009).

Within the context of experiential learning activities, it is also useful to present data about the underlying theoretical portion of the PPM in terms of its benefits to improving quality of care, its relationship to RN work satisfaction, and how others have incorporated it. Such evidence provides nurses with important reference points from which to base their evolving practice. Having participants appraise themselves, review pertinent literature, and relay their findings to others is a useful experiential learning approach for practicing clinicians.

Modifying Work Roles and Responsibilities

As the PPM becomes more understood in the organization, it follows that some work-role revisions might be necessary. These revisions most often include RN roles, but also frequently include those that support RN work (e.g., unlicensed assistive personnel) and those that complement nursing work (e.g., other health care providers).

For nursing, clear work roles contribute to overall quality by identifying the most appropriate personnel for the revised clinical functions and ensure that the work carried out is aligned with the PPM.

Conducting a role-delineation (or job analysis) review helps to fully understand and describe the current duties and responsibilities of a position as well as the knowledge, skills, and abilities required to perform well in the position. The aim is to have a complete picture of the position—what is actually done and how—in relation to the PPM. More specifically, describing practice expectations and performance requirements as they link to the underlying theoretical framework of the PPM provides the necessary background for deciding to revise existing job descriptions. Because this is the basis of most human resource activities, it is prudent to involve this department in the process.

Role delineation usually involves collecting information about the responsibilities associated with the current roles, identifying knowledge domains and required skills, analyzing and interpreting the results, creating revised job descriptions (if necessary), confirming the link between revised performance expectations, knowledge, and skills and the underlying nursing theoretical framework, and developing a final detailed performance description.

The types of information collected during role delineation are specific to each organization; however, typical kinds of information that are gathered include (Roberts & Hughes, 2013):

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