Power of Professional Practice Models: Impact
Impact, future, value, partnerships, networks, learning communities
By the end of this chapter, readers will be able to:
1. Describe the potential impact of professional practice models (PPMs)
2. Discriminate between the terms dissemination and impact
3. Evaluate the types of impact
4. Describe three methods used to link value-based outputs with others
5. Differentiate among partnerships, networks, and learning communities
6. Identify at least three sources of external information that can facilitate future planning
IMPACT OF PROFESSIONAL PRACTICE MODELS
For health systems, integrating professional practice models (PPMs) simultaneously carries with it risk and opportunity. For instance, the effort requires tremendous investment of resources and, if it fails, the investment could be wasted, a huge risk for most health systems. On the other hand, the opportunities for expediting the implementation, improving nursing practice, and/or positively influencing patient outcomes may exceed intended outcomes and have significant utility for others if the PPMs are translated into real-world solutions. For example, employee passion for a particular PPM component, a successful and efficient approach to implementation, popular training strategies, valid and reliable evaluation methods, or improved patient outcomes might yield practical dividends that have implications for populations, professional practice, resource consumption, policy, teaching, and knowledge advancement. In fact, PPM integration at one site is not necessarily an end in itself; rather, positive consequences can generate significant value at many locations. New ways of practicing nursing, innovative indications for existing nursing practice, cost savings, advancements in knowledge, increases in employee work engagement, revised policies, and important and improved patient outcomes are examples of noticeable outcomes that provide evidence of impact.
Impact refers to the effect or consequence of an innovation (e.g., a PPM) or research findings that makes a difference in the real world (versus academia), implying that actions or activities that lead to some change are involved (Chandler, 2014). For instance, if an innovation has been successfully demonstrated in one site and is used by practitioners in another site leading to similar improvements, its impact may be viewed as effective. However, if additional organizations take up the innovation or if the degree of improvements is greater than originally demonstrated, the innovation is considered to have a powerful impact.
Although most of the literature on impact refers to the results of research, the investment of time and resources required to integrate large-scale change, as intended by PPM integration, demands consideration.
Because health care expenditures continue to rise and reimbursement policies have changed, monetary resources remain limited and accountability for large investments has become a major leadership responsibility. Thus, demonstrating the value of PPM integration through the eyes of stakeholders at all levels requires leaders to adjust results reporting from gut feelings or activities completed to providing real evidence of value (evidence-based leadership). Such evidence also is a necessary antecedent to others’ utilization of demonstrated successes.
For example, using or citing a reference to an innovation from a peer-reviewed journal suggests that it is perceived by others in the field as having an influence on the field and/or society as a whole and may benefit additional organizations or populations. Or, adopting a well-demonstrated theoretical framework at multiple sites, and then disseminating it through an annual system-wide leadership conference points to impact. Using evidence from PPM integration in this way may accelerate benefits and create opportunity for others and the profession.
THE NATURE OF IMPACT
Impact shifts what is learned through innovation (or research) at one site to actionable recommendations and applications of such knowledge in a variety of practice settings and contexts. It is similar to the research term knowledge translation, which has been defined as: “the synthesis, exchange, and application of knowledge by relevant stakeholders to accelerate the benefits of global and local innovation in strengthening health systems and improving people’s health” (Pablos-Mendez & Shademani, 2006, p. 82), with the ultimate goal of enabling and reinforcing change on a larger scale. Furthermore, impact is an interactive process reinforced by ongoing exchanges between the original innovators who created the knowledge (lessons learned and best practices) and those who use it.
The Payback Framework (Buxton & Hanney, 1996), a widely used model for assessing the impact of research, suggested that awareness and new knowledge, better informed research, policy recommendations, commercial product development, adoption of the innovation by practitioners and the public, improved health, cost reduction, and other economic benefits were “paybacks” from the research process. The United Kingdom’s Economic and Social Research Council (2015) classifies impact as:
• Instrumental: Influencing the development of policy, practice, or service provision, shaping legislation, altering behavior
• Conceptual: Contributing to the understanding of policy issues, reframing debates
• Capacity building: Technical and personal skill development
A similar way of imagining the benefits from investments of health systems toward integrating PPMs can be offered. Because most health systems receive public resources and have missions that “serve society” (albeit locally), successful evidence from large-scale projects demonstrates to governments, stakeholders, and the wider public, the value (impact) of such projects. Furthermore, as nurses, our contract with society includes facilitating the progress between what is known and what is practiced, spending resources wisely in the process.
To ensure that innovation investments are spent most effectively and remain a priority in the face of limited resources, it is essential that nurses and nurse leaders obtain the most reliable estimates of the value of innovation investments.
From the patient’s view, value may include access to services, quality of those services (including safety and outcomes), and perceptions about the experiences. However, in the eyes of top-level administration, tangible (e.g., reduced costs resulting from shorter lengths of stay, reduced nurse turnover) and intangible measures (e.g., employee teamwork, corporate image) are used together to create a monetary profile that demonstrates how an organization benefitted from an innovation. Responsible use of health systems’ funds demands balanced and credible evidence that demonstrates benefit to the system (e.g., better market share, reduced costs, increased brand awareness) to stimulate others’ use, the real meaning of impact. The process of demonstrating monetary value (of PPM integration)—return on investment (ROI)—is a systematic process that is related closely to the evaluation plan (in other words, the data inputs, objective measurement, and results). The ROI can then be calculated as a percentage: earnings divided by investments or the net benefits in dollars (project benefits minus the costs) times 100 (Buzachero, Phillips, Phillips, & Phillips, 2013). Communicating these results to various stakeholders helps convince them that the system’s resources were wisely spent and helps ensure the project’s continuance.
Often, nurses and nurse leaders fail to see that the financial success of a large-scale project, such as PPM integration, is their responsibility.
Carefully aligning and realigning (over time) PPM integration with important health system business goals is necessary to drive perceived value.
For example, in the early developmental period, cautiously choosing evaluation metrics that align with corporate measures of performance (e.g., patient experience, employee engagement, reduced errors, patient wait times, unplanned readmissions) establishes a fundamental link to business goals.
Anticipating how to translate intended changes in patient or nurse outcomes to dollar values ensures a more efficient reporting process.
Realizing that external and contextual factors can influence the agreed-on outcomes measures, nurses and nurse leaders should clarify these ahead of time and use them to interpret and explain results. Working effectively with key leaders in other departments (e.g., the financial department, decision support), and insisting on their ongoing support, is also needed to contribute to project success.
The impact of PPM integration on a health system and beyond varies as the project adheres (or not) to the original values and implementation strategies, and adapts based on experiences and improvements used, suggesting that levels of impact may be observed.
Identifying how key stakeholders will benefit from the knowledge obtained in an integration project, by categorizing the evidence gained into system or practice groups, creating opportunities to interact with them (through various dissemination activities), and providing practice guidance may increase the extent of impact.
The number of successfully demonstrated and documented lessons learned/best practices that are cited by others; the number of sites and contexts in which knowledge from an integration project is used; the number of patients affected; the copyrights or licenses developed; the number of policies informed or developed; the number of sites where new work processes become institutionalized; and the new capacities of employees affected are just a few examples of the extent of impact (level, range, or scope). Capturing these outputs adds to the evidence base needed to demonstrate value and is powerful in terms of persuading others. Documenting and advancing such degrees of impact, along with identifying enablers, is a leadership responsibility.
CREATING HIGH-IMPACT CONNECTIONS
The ability to rapidly mobilize knowledge is central to transforming professional nursing practice and positively impacting patient outcomes. But it is generally not sufficient to merely be aware of and/or access relevant knowledge because many studies have demonstrated the long time lag between available evidence and its uptake in practice (Williamson, Almaskari, Lester, & Maguire, 2015). Rather, to effectively and rapidly influence others, the information (or content) must be understood and match user needs, various communication strategies must be used, and stakeholders must engage in the new innovation and effectively apply it, all prerequisites to extending reach (Woolf et al., 2015).
Knowledge translation is a contextual, interactive process that is often complex and dependent on relationships for its effectiveness and efficiency. Baumbusch et al. (2008), referring to research, conceptualizes this “as a dialogic, collaborative engagement between researchers and practitioners through which people come to reflect on what they do, and its consequences, and identify what they might do differently” (p. 134). However, the knowledge generated as a result of integrating a PPM has many implications for others that, if not incorporated efficiently, contributes to significant delays in its uptake in additional health systems. Thus, actively engaging in ways to link value-based outputs with others is a professional responsibility.
Respecting the context of others, including their unique needs, helping to translate outcomes derived at one site into practical solutions at their sites, and establishing collaborative forums for dialogue facilitate this process. Likewise, respecting the outputs identified by original users, actively listening to their perspectives, choosing to “see” the relevance of such knowledge and apply it in different settings, all in the context of mutually beneficial relationships, facilitate more widespread application.
Various methods and forums that ease the transfer of knowledge gained from one site to others already exist, whereas others are emerging. For example, existing written approaches, such as the literature, professional conferences, websites, published toolkits, and case studies, make a wide variety of new knowledge available to others. But more active approaches, such as partnerships, interactive workshops, learning communities, and collaborative networks, establish the necessary linkage and exchange between knowledge producers and knowledge users to create lasting impact. For example, academic–practice partnerships, defined as strategic relationships between educational and clinical practice settings that are established to advance their mutual interests (AACN, 1990) “are a critical key to strengthen nursing practice and assist nursing in leading change and advancing health care in our communities” (Gale & Beal, 2013, p. 21). Successful benefits in both parties have been reported (Beal, 2012); adopting this model between health systems may yield similar results. Furthermore, research networks are alliances between multiple practice sites that agree to work together to answer common research questions. Unlike traditional research conducted in universities, research networks involve relationships between researchers and clinicians from real-world practices. Similarly, health systems aligned around similar PPMs may use such networks to advance research and evaluation of PPM integration.
Originating in education, professional learning communities include groups of interested professionals (e.g., direct care nurses and nurse leaders) who share common goals and attitudes and who meet regularly over time to collaborate on mutual goals (e.g., accelerating the integration of PPMs; Smith, Shochet, Keeley, Fleming, & Moynahan, 2014). The group uses active techniques to better understand integration such as patient-centered discussions, patient-led seminars, case studies, dialogue with clinical nurses in the real world, site visits, interactive conferences, collaborative projects, pilot studies or demonstration projects, and critical reflection. Through such dynamic and collaborative methods, the necessary give-and-take between various professionals undertaking a similar goal establishes strong and vibrant relationships that are essential in driving application.
In active forums such as these, similar aims are shared, including the desire to understand what works in “real-world” settings.