Professional Practice Models: Raising Awareness
Professional practice models (PPMs), models of care, professional practice model components
By the end of this chapter, readers will be able to:
1. Summarize a professional practice model
2. Compare traditional and contemporary components of professional practice models (PPMs)
3. Distinguish between PPMs and patient care delivery systems (PCDSs)
4. Evaluate patient, nursing, and health system implications of PPMs
DEFINITION OF A PROFESSIONAL PRACTICE MODEL
Professional practice models (PPMs) are frameworks or systems that uphold and define the professional practice of nursing in an organization. Ideally, PPMs provide structure for nursing practice that is consistent with professional values, creates meaning for nurses, and offers benefits to patients and families. Such models help RNs feel connected to their own professional values, see the link between their own practice and the work of the institution, and showcase nursing’s contribution to health care. More specifically, PPMs make visible the often invisible work of nursing. In doing so, RNs are often better able to focus on the priorities of their practice, set goals, improve their practice, and use the framework to guide research, thereby demonstrating the effect of their practice.
Hoffart and Woods (1996) first defined a PPM as a “system (structure, process, and values) that supports RN control over the delivery of nursing care and the environment in which care is delivered” (p. 354). The ultimate goal of a PPM is to improve the quality of patient care, but also to advance the practice of nursing by carefully delineating the roles and responsibilities of professional nurses and ensure their accountability for monitoring and evaluating performance. Thus, a PPM is a multicomponent system that serves as a guidepost for nurses and fosters the alignment of nursing practice with organizational priorities and professional values.
Often, a visual representation of a PPM is created and used by organizations to clarify the complexities of professional nursing practice. The resulting diagram depicts the various components of nurses’ contributions and fits them together to reveal the entirety of nursing within a given institution.
COMPONENTS OF PROFESSIONAL PRACTICE MODELS
Traditionally, five coordinated components comprise PPMs, each building on the other and leading to exemplary professional practice that ultimately supports nursing autonomy, empowerment, innovation, and high-quality patient care (American Nurses Credentialing Center [ANCC], 2013). The five components include (a) the organizational mission and related nursing values or philosophy; (b) nursing professional roles, responsibilities, and relationships (typically derived from nursing theory); (c) a PCDS; (d) governance and decision making; and (e) a system of recognition/rewards.
Because the mission of an organization contains value statements and directs the energies of an organization, it is fitting that it provide the foundation for health systems’ PPMs. For example, at the University of California San Diego (UCSD) Health System, the mission states: “to deliver outstanding patient care through commitment to the community, groundbreaking research, and inspired teaching” (UCSD Medical Center, 2014). As you might guess, ideas, such as stellar patient care, collaboration, commitment, research, and ongoing learning, could be gleaned from this mission. As it turns out, the resultant nursing philosophy statement is as depicted in Figure 1.1.
This mission and nursing philosophy advocate excellence through caring relationships, use of evidence, accountability, and teamwork that, one hopes, informs the subsequent roles, responsibilities, and relationships apparent in nursing practice. Using another example, at Indiana University Health, the mission reads: “Indiana University Health’s mission is to improve the health of our patients and community through innovation and excellence in care, education, research and service,” suggesting novel approaches to excellence, education, research, and service (Indiana University Health, 2014a). As it turns out, the nursing philosophy at the Bloomington, Indiana, hospital states: “nursing is a scientific discipline that takes a holistic approach to the diagnosis and treatment of potential and actual responses to illnesses. The goal of nursing is to lessen the effects of illness, promoting comfort and healing and assisting patients whether that is an optimum state of health or a dignified death” (Indiana University Health, 2014b). The mission and nursing values articulated in the philosophy statement suggest ongoing research and evidence—nursing is a scientific discipline—and holism, undergirding nursing’s practice.
Nursing professional roles, responsibilities, and relationships comprise the second component of PPMs and are usually derived from nursing theory (but are not required). In fact, many organizations successfully design their own descriptions of nursing’s roles, responsibilities, and relationships. Others prefer to adopt an existing theoretical model that fits with the articulated mission and nursing philosophy. In this component, how nurses practice, collaborate, communicate, and develop professionally is addressed. What professional nurses actually do when they provide care to patients (e.g., their day-to-day role, including what they are held responsible for), how they function alongside others to complete the work (relationships with the health care team), and how professional nurses grow and develop (e.g., continuing education, advancement systems, competencies) requires quite a bit of forethought and consensus building. The UCSD Health System described earlier uses the Quality-Caring Model© (Duffy, 2009, 2013) to define nursing practice that considers caring relationships at the core of nursing practice and specifically defines the role of the professional nurse as “to engage in caring relationships so that self and others feel cared for” (p. 38), in order to positively influence intermediate and terminal health outcomes. On the other hand, the Synergy Model (AACN, 2014) describes nursing practice at Indiana University Health. In this model, the goal of nursing is to “restore a patient to an optimal level of wellness as defined by the patient” and is accomplished when “the needs and characteristics of a patient, clinical unit or system are matched with a nurse’s competencies” (AACN, 2014). This component of PPMs must “fit” with the mission and nursing philosophy and drive the PCDS. See Figure 1.2 for a consistency example.
PCDSs detail broadly the various ways in which nursing work is coordinated and organized to meet patient care needs.
In essence, PCDSs include the wide range of practices and activities that occur in everyday settings where caregiving and care receiving are practiced (Lackman, 2012). PCDSs include work processes, communication patterns both within and outside the discipline (e.g., shift reporting, hand offs, interprofessional discourse), resources (e.g., staffing, assignments, staff mix), the context (e.g. the physical and cultural environment), and specific nursing interventions or practices derived from nursing theory that benefit patients and families (e.g., specific processes that nurses do with patients and families such as individualized education based on a health literacy assessment or a theory-derived intervention). In particular, PCDSs address professional nurses’ scope of practice, continuity and transitions in care, accountability for clinical decision making, and outcomes. They also include how nurses are assigned to meet patient needs, what additional personnel are involved, who does what, and how patient care is recorded. Additionally, PCDSs describe the type and number of caregivers needed to carry out patient care. The work environment or the context of nursing practice is also considered. Organizational characteristics, such as leadership, support systems, and interprofessionalism, are components of the work environment along with the physical space. Finally, how nursing care is evaluated and modified is usually described in the PCDS.
Four traditional PCDSs—total patient care, functional nursing, team nursing, and primary nursing—have been used to operationalize the work of nursing (Tiedman & Lookinland, 2004). In total patient care, RNs assume complete care for patients. An example of this is private duty nursing or an intensive care unit or postanesthesia recovery room situation where an all-RN staff is employed. In a functional system of care, patient care needs were divided into tasks and distributed among a group of nurses and ancillary caregivers. For example, nurses, who were assigned to distribute medications for their shifts, administered all the medications to all patients on a unit or part of a unit. Team nursing used a system in which RNs led a team of unlicensed assistive personnel in the care of a group of patients, oftentimes defined by the geography of a unit (e.g., one wing). In the late 1970s and early 1980s, primary nursing, in which RNs assumed 24-hour accountability for patient care for a defined number of patients, emerged. In this PCDS, RNs used “associates,” who could be other licensed professionals, or assistive personnel to guarantee that patient needs were met 24/7. However, the primary nurse assumed accountability for all care, including discharge planning and care that took place when he or she was off duty. Each of these PCDSs has benefits and challenges to nurses, patients, and health systems, although little systematic evidence has shown benefits of one system over another.
In more recent years, other PCDSs have emerged. For example, the Attending Nurse Model (Watson & Foster, 2003), which parallels the well-known Attending Physician Model; use of unlicensed assistive personnel in various nurse extender systems, such as the Partnered Model (Krapohl & Larson, 1996) or the Nonpartnered Clinical Model (Kenney, 2001); case management models (Girard, 1994); and, more recent, interprofessional disease management models for chronic care (Wagner, Davis, Schaefer, Von Korff, & Austin, 1999). In larger care delivery systems that go beyond nursing, such as accountable care organizations (ACOs) and patient-centered medical homes (PCMH), alternative models are developing. Regardless of the approach, PCDSs are one component of a PPM that is informed by the three preceding components: mission; nursing values; and nursing professional roles, responsibilities, and relationships.
How nursing is governed and decisions are made is the next component of a PPM. This component is closely related to the Magnet® criterion of structural empowerment and refers to those structures in a health system that support how decisions about nursing practice are made. It is linked most aptly to the concept of power, which implies authority, control, and the ability to influence or make decisions or to generate results. In nursing, it is only recently that power has been afforded to those who actually deliver care.
Shared governance, as coined by Cleland (1978) and later widely popularized by Porter-O’Grady (1992), is a system by which nurses control their practice as well as influence traditional administrative decisions. Shared governance programs typically are designed around committees that meet regularly and include staff nurses, educators, and managers who tackle issues such as practice, resources, quality and safety, education and development, research, and evidence-based practice (EBP). One approach is to organize several committees and have an overarching coordinating council that integrates decisions made by the individual committees. Another approach is to create a real Congress-type model in which representative nurses vote as a group on issues that directly impact their practice.