CHAPTER 4

Components of Professional Practice Models: Design

KEY WORDS

Values clarification, theoretical framework, patient care delivery systems, shared leadership, shared governance

OBJECTIVES

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

1.  Appreciate the values inherent in professional nursing

2.  Choose well-aligned theoretical frameworks that uphold nursing’s disciplinary perspective

3.  Analyze related elements of patient care delivery systems (PCDSs)

4.  Apply principles of shared leadership to the workplace

5.  Create a visual representation of a professional practice model (PPM)

NAMING THE VALUES INHERENT IN PROFESSIONAL NURSING

Nursing values connote particular beliefs about professional nursing and establish how one feels about the profession. These work-related values are different from, but related to, those personal values that we use to frame our lives. Work values are a subset of personal values that represent enduring views concerning nursing practice and the profession that shape how nurses conduct themselves, make decisions, and commit to the work.

Although nursing values are oftentimes based on individual religious and sociocultural perspectives, as well as on certain life experiences, they are further shaped by education, work experiences, and the context in which one works.

In times of great change or competing priorities (such as integrating a professional practice model [PPM]), or when working with underdeveloped employees, nursing values provide the stability to persevere. In one editorial, the nursing values of human dignity and respect, altruism, social justice, precise care, and appropriate relationships were identified as most typical (Condon & Hegge, 2011). Others have spoken of trust, nearness, sympathy, support, knowledge, and responsibility (Snellman & Gedda, 2012). Still others have identified advocacy, caring, compassion, and excellence as significant nursing values (Watson, 2006). Many of these beliefs are contained in the American Nurses Association (ANA) Code of Ethics (2015). Clarity and attention to individual work-related values help raise nurses’ awareness, direct their priorities, and enable nurses to make choices. In fact, some have found that when individual work-related values were consistent with role performance, reduced job dissatisfaction, increased motivation, and increased retention followed (Ravari, Bazargan-Hejazi, Ebadi Mirzaei, & Oshvandi, 2013).

Shared work-related values facilitate organizational goals by confirming role definitions, establishing appropriate competencies, directing educational activities, enabling teamwork, providing a starting point for change, organizing strategic priorities, and contributing to professional identity. Through shared values, organizations build cultures that contribute to or detract from goals.

Furthermore, the value set can be used to craft a nursing philosophy that helps explain nursing’s shared reflection of its practice, including its contribution to the community served. When aligned with the larger organization’s mission, shared professional nursing values position health systems to better actualize the organization’s long-term vision.

The process of values clarification involves a brief activity or a set of brief activities that help individuals identify, clarify, and prioritize those beliefs about nursing that are central to them.

Usually, values clarification in nursing requires representatives from multiple areas of a health system to gather in a quiet place for 1 to 2 hours with a facilitator. As an alternative, in a large institution where it is difficult to get many nurses together at one time, scheduling small groups at different times until all have been involved is an option. The key to developing and realizing a common shared vision is to involve as many stakeholders as possible in the process.

The facilitator can be anyone who has some experience with groups and does not necessarily need to be a nurse. Usually, the exercise starts with a question to help identify the main purpose. For example, what do you believe is the ultimate goal of nursing? This question can then be followed by a second one that is more specific such as: How can this goal be achieved? If necessary, other questions can be asked to stimulate more discussion (see Table 4.1).

Table 4.1 Suggested Values-Clarification Questions

Once certain values/beliefs are named, the facilitator can lead a dialogue about them, freely discussing the members’ reactions to them, emphasizing that various nurses will react differently.

Second, the facilitator can probe potential organizational consequences of using these values to guide nursing practice by asking questions such as:

On the other hand, the facilitator can present the group with a prearranged list of nursing values and ask participants to rank order those they feel are most significant. Although efficient, a drawback of this method is the lack of deep reflection on the part of the participant. Using facilitation techniques, such as dialogic conversation, allowing equal voice, paraphrasing and mirroring, drawing people out, deliberate refocusing, and managing group energy ensures a comprehensive and participative process (Kaner, 2014). As specific values are articulated, they are documented and a system of analysis is used to prioritize those with the most significant meaning to the group. For example, the Delphi technique (Dalkey & Helmer, 1963; Dalkey, 1969) can be used to communicate and collate multiple iterative responses and then generate consensus on a final list of nursing values. It is prudent to keep this final list short for ease of comprehension and integration into existing documents. When finalized, the group or groups then disseminate their results to a larger group (sometimes the practice council) for approval and record keeping. See Appendix A for an outline of a values-clarification workshop. The finalized values are then confirmed to others through organization-specific documents such as nursing philosophy statements, commitment declarations, or proclamations of what characterizes nursing in a certain health system. For example, the Advocate Health System in Illinois generated a list of nursing values, labeling them “The Advocate Nurse” to distinguish nursing at this organization. They include:

The Advocate Nurse (2014)

Advocate Health System

Chicago, Illinois

ALIGNMENT OF ORGANIZATIONAL MISSION, NURSING VALUES, AND STRATEGIC DIRECTION

Organizational missions vary but they relate to a health system’s ultimate purpose (e.g., patient care, research, or education). A mission statement suggests what an organization is, what it does, and, in some cases, where the organization plans to be in the future.

For example, a hospital’s mission statement might read:

The articulated nursing philosophy (with embedded nursing values), however, states:

The values expressed in the nursing philosophy statement suggest patients’ rights to quality care, the importance of evidence-based practice (EBP), research and performance improvement, and nursing’s contribution to overall health. And the mission statement clearly outlines the hospital’s commitment to patients in terms of providing quality and compassionate care.

In a side-by-side comparison of the two statements, consistencies can be identified. In this case, both documents are aligned, allowing for optimal integration of the PPM (see Table 4.2). If, after careful appraisal, however, the mission statement and the articulated nursing values lack congruency, it is important to regroup and consider creating a more consistent set of documents. In most cases, the mission statement cannot be revised and it drives organizational plans, image, and performance.

One approach to resolving inconsistent documents is to take the time to examine the mission statement and selected nursing values together with common everyday nursing tasks. This provides insight into the organization’s workflow that may drive a reiteration of the values. In performing this exercise, some health systems find that the complexity of the system may interfere with actualizing the core values. Another alternative is to look for those individuals who best reflect the stated values and then determine whether these employees exhibit behaviors that represent the organization’s mission. Any inconsistencies should be addressed. Taking these examples back to the values clarification group and renaming only those core values that are fundamental to the organizational mission better positions the health system to realize successful PPM integration.

Table 4.2 Consistency Between Mission Statement and Nursing Values

Aligning the organizational mission and core nursing values must occur at a variety of levels across a health system, requiring strong leadership and ongoing monitoring. Understanding and recognizing this important relationship, taking a “big picture” view with the ability to appreciate many different perspectives, being able to identify common themes, make decisions despite political agendas, and consider implications of actions are valuable leadership qualities.

CHOOSING A THEORETICAL FRAMEWORK

A theoretical foundation strengthens nursing practice by providing parameters for that practice, a common disciplinary language, a basis for research, guidance for specific interventions, and the foundation for advancement systems (Smith & Parker, 2015). Choosing or developing a framework that is consistent with stated nursing values is crucial. Furthermore, the framework makes explicit what is implied by the values statement and unifies nursing practice across a health system.

Grounded by the organizational mission statement and nursing values, a review of several existing theories, including the authors’ assumptions, major concepts, and relationships, should proceed with special attention to the population served. Acquiring and reading the authors’ primary works and using an acceptable evaluation system (e.g., criteria for evaluation of theory; Fawcett, 2005; Chinn & Kramer, 2011) to evaluate the theories is a good process for choosing one that best represents a good fit with the organization’s mission, nursing values, and the particular theory (Table 4.3).

Although many organizations choose to adopt an existing nursing theory, several organizations have developed their own foundational principles to guide nursing practice. For example, Banner Health System developed a conceptual framework starting with broad guiding principles and assumptions and continuing with contributions to patients, the profession, and society (Mensik, Martin, Scott, & Horton, 2011).

Whether choosing an existing model or developing one’s own, the selection should be precise, with multiple views from across the organization considered. Edmundson (2012) details the process used at one pediatric hospital using a representative selection team, in-depth readings, multiple meetings, and communications with other health systems.

Table 4.3 Considerations for Choosing a Nursing Theoretical Framework

THE PATIENT CARE DELIVERY SYSTEM

The term patient care delivery system, refers to how care is organized and coordinated in health systems. More specific, it describes the approach to care delivery, the skill sets required, authority and accountability for decision making and resultant patient outcomes, how multiple health care workers communicate and coordinate care, environmental artifacts and equipment that support the process, and what resources are required. Traditionally, PCDSs referred to the acute care environment and were associated with nursing and ancillary staff (e.g., team nursing, functional nursing, total patient care, primary nursing). Later, although still referring to nursing in the acute care environment, systems, such as the partnership model, sometimes referred to as coprimary nursing, were designed to make more efficient use of the RN (Marquis & Huston, 2000).

In the partnership model the RN is partnered with a licensed practical nurse (LPN) or an unlicensed assistive personnel (UAP), and the pair work together consistently to care for an assigned group of patients. Another system, modular nursing, calls for a smaller group of staff providing care for a smaller group of patients. The goal of this model was to increase the involvement of the RN in planning and coordinating care and maximize communication among team members (Anderson & Hughes, 1993).

Case management is another care delivery system; in the case management system an RN coordinates the patient’s care throughout the course of an illness. Case management is generally used for chronically ill, seriously ill or injured, and long-term, high-cost cases. In this system of care, because of the chronic, long-term nature of the patient population, the role of the RN is much broader than a specific unit and today this model is used by both health systems and most major health insurance companies. Health systems use case management to augment unit-based systems and insurance companies use it to manage the use (and ultimately costs) of health care services for their clients.

The ANA defines nursing case management as

Although case management is known as a form of patient care delivery for one site, in today’s remodeled health system, the term patient care delivery system has taken on a broader meaning, one that crosses health care settings, such as acute hospital care, to include larger integrated arrangements that extend into the community, align multiple health care providers, and are coordinated through health information systems. For example, the patient-centered medical home includes patient-centered, team-based care that is coordinated across traditional health care system boundaries, with enhanced access using alternative methods of communication (e.g., remote monitoring, electronic reminders, and networked electronic health records), and a systems-based approach to quality and safety (Scholle, Torda, Peikes, Han, & Genevro, 2010).

Whereas the care team traditionally included RNs, LPNs, and nursing assistants (NAs), current care teams include all relevant health care providers, including the family, whose collective efforts result in optimal care. Of course, health systems also design their own PCDSs. For example, at MD Anderson Cancer Center in Houston, Texas, a primary team approach was designed that incorporates a microsystem of nurses and other health team members who cooperatively and consistently provide care to a small group of patients. To facilitate the primary team, a master’s-prepared nurse supports continuity and coordination among the members, builds relationships, uses outcomes data to expedite practice changes, and coaches and develops primary team members (Duffy, 2013). Although each of these approaches offers benefits and challenges, both the traditional and newer approaches to patient care delivery lack good evidence of their value (e.g., clinical, experiential, and cost outcomes). It is imperative that PCDSs be evaluated to determine their ultimate value.

As such, a better grasp of the tasks and roles of providers, as well as patient outcomes, results. Designing the PCDS is best accomplished through a group process approach with all levels of professional nursing involved. In other words, over a series of meetings, a facilitator works with a group of staff nurses, nurse leaders, nurse educators, and others to develop the blueprint for how nursing care (as defined by the mission/values and theoretical framework) will be delivered. Whether adopting an existing PCDS or designing one specific to an institution, a well-defined series of activities enables appropriate alignment with the values and beliefs that formed the foundation of the PPM (see Table 4.4).

First, a thorough understanding of the population served is essential. Understanding patients’ and families’ needs and preferences is a hallmark of patient-centered care (Institute of Medicine [IOM] Committee on Quality of Health Care in America, 2001) and is an overriding theme in today’s health system.

Being aware of these perspectives enables analysis of the facility and the staff who best can provide these services, assurance that the overall experience of care is optimal, enables safety, and sets up the conditions for transparent communication between patients and health care providers. In this way, a true emphasis on patients as partners versus patients as passive recipients is upheld. As the population becomes better known, designers can then respond to their needs and preferences by reviewing the mission/values and nursing theoretical framework, already defined, to develop a set of guiding principles that will drive the type of nursing care that will be delivered.

Table 4.4 Activities Used to Design a Patient Care Delivery System

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