Professional Practice Models



Professional Practice Models


Diane L. Huber



imageevolve.elsevier.com/Huber/leadership/


The goals of safe and successful patient care delivery include high-quality and low-cost care with the achievement of patient and family outcomes and satisfaction levels. The ability to reach these objectives depends on the organization’s approach to the matching of human and material resources with patient characteristics and health care needs via a model of professional practice for care delivery.


Both assignment and delegation are methods used by managers to deliver patient care within the structure of the health care system. The determination of the structure and method by which assignments are made is a managerial responsibility. Although this is part of a process of developing a model of nursing care delivery, pure nursing care delivery models, mainly reflecting the care of the patient by registered nurses on a discrete hospital unit (Minnick et al., 2007), are characteristic of the “siloed” approaches of the industrial age. These approaches are seen as not well matched to organizational effectiveness in an era of primary care–based service delivery such as in Patient-Centered Medical Homes (PCMHs) and Accountable Care Organizations (ACOs).


Nursing leaders are the primary designers and stewards of systems for the provision of client care and the betterment of the organization (Morjikian et al., 2007). Nurses, as the major providers of care, develop and implement patient plans of care in collaboration with the multidisciplinary health care team within the framework of the care delivery model. The model of care delivery has a direct relationship to the allocation of control over decisions about client care. It is the means through which nurse managers delegate effectively and thereby free up and manage time as a scarce resource. The type of care delivery system or care model is seen as determining whether professional practice exists among the nursing staff on a particular unit because delivery systems constrain nursing decision making. This means that autonomy over practice decisions is determined largely by the care model and the resultant nurse decision-making latitude. The type of care delivery system used has implications for job satisfaction, the character of professional practice, and the amount of authority that is actually transferred to the staff.


The determination of a nursing care model or system of care delivery depends on the identification of organizational structures, patient care processes, and health care provider roles that are necessary to achieve care goals. Examples of structure and process criteria are found in Box 15-1. Trends in the health care environment strongly influence organizational structure.



BOX 15-1


Direct and Indirect Patient Care Functions




Data from Fuzard, R.T., Fox, D.H., & Wells, P.J. (1999). Performance of first-line management functions on productivity of hospital unit personnel. Journal of Nursing Administration, 29(9), 12-18. Reprinted from Deutschendorf, A.L. (2003). From past paradigms to future frontiers: Unique care delivery models to facilitate nursing work and quality outcomes. Journal of Nursing Administration, 33(1), 52-59.



DEFINITIONS


There is confusion over the differences between the terms professional practice models and models of care delivery (Wolf & Greenhouse, 2007). These concepts are often used interchangeably, yet their meanings are quite different. Professional practice models (PPMs) refer to the conceptual framework and philosophy under which the method of delivery of nursing care is a component. PPMs describe the environment and serve as a framework to align the elements of care delivery. The professional practice model can be thought of as a link between the problems presented by client populations, the purposes of professional occupations, and the purposes of health care organizations. For any practice model, the degree of integration of the nursing care given to a client, the degree of continuity in assignment of nursing personnel caring for a client, and the type of coordination used to plan and organize the client’s care need to be consistent with general client characteristics, available nursing resources, and the organizational support available to nursing (Mark, 1992). The five subsystems of a PPM are: professional values, professional relationships, care delivery model, governance, and professional recognition and rewards (Shirey, 2008).


Examples of professional practice models include Relationship-Based Care (Koloroutis, 2004), the Synergy Model (Hardin & Kaplow, 2005), and Watson’s Caring Model (Watson & Foster, 2003). Hoffart and Woods (1996) described five subsystems in a professional nursing practice model:



Models of care delivery are the operational mechanisms by which care is actually provided to patients and families (Person, 2004). A care delivery model is defined as a method of organizing and delivering care to patients and families to achieve desired outcomes. It organizes the work. The basic elements of any care delivery systems are identified as nurse/patient relationship and clinical decision making, work allocation and patient assignments, interdisciplinary communication, and the leadership or management of the environment of care (Manthey, 1991; Person, 2004). Coordination is a critical component that must be considered to manage task interdependencies upon which process and clinical outcomes rely. Relational coordination (Gittell et al., 2000) is described as the management of the multiple dimensions of communications and relationships between and among health care providers that are necessary to provide quality and efficient care.


Care delivery models must address both direct patient care functions (hands-on or delivery of health care services) and indirect patient care functions (management of providers and the environment) (Deutschendorf, 2003) (see Box 15-1). Direct patient care functions are facilitated by and depend on management, or indirect functions. For example, the client care assignment system is an aspect of operations included in indirect patient care functions. It is how the work is distributed. Using human resource decisions such as staffing and skill mix, a framework for the deployment of nursing staff and other interdisciplinary providers and their assignment to client care can be determined. Although the nurse manager is ultimately accountable for the achievement of direct and indirect patient care functions, the scope of responsibility necessitates appropriate delegation and assignment to competent unit staff. Delegation and assignment of management functions are vital to developing and maintaining professional nursing practice.



BACKGROUND


Executive leadership is responsible for making decisions about and designing strategies to create a climate and environmental context around the provision of nursing and health care services. Organizational environments exert a strong influence over patient care delivery, either positive or negative. Nursing care delivery can be seen as the dynamic balance between routine resource management and the structure, process, and outcomes of practice. One feature is that the system for distribution of nursing personnel must ensure that staff members of the right skill mix and numbers are promptly deployed so that clients are cared for in an appropriate and timely manner. Studies have demonstrated the impact of skill mix and nurse staffing on patient outcomes (Aiken et al., 2002; Kane et al., 2007; Needleman et al., 2001), further clarifying the need for appropriate role and resource deployment. The four strategic decisions to make are a philosophy of resource utilization, a choice of delivery system, common and individual practice expectations, and a development of the role of the registered nurse (RN) (Manthey, 1991). These four strategic decisions may be made at different levels in any organization. If these decisions are made only by the chief nurse executive, then shared governance and decentralization do not exist.



Professional Practice Models


A PPM is a framework and a structure that glues together elements of the work environment, management and governance, and the needs of patients and families to ultimately achieve outcomes, including care coordination and integration. The nursing practice environment contains those organizational or unit attributes that facilitate/constrain professional nursing practice (Arford & Zone-Smith, 2005). The concept of “magnetism” arising from the Magnet Recognition Program® addresses organizational attributes necessary for attracting and retaining nurses. Nurses want a work environment that allows them to feel productive, have control over work, exhibits respect for employees, and gives feedback on job accomplishment (Arford & Zone-Smith, 2005). The Exemplary Professional Nursing Practice component of the Magnet model measures aspects of the PPM and model of care and their outcomes (Wolf et al., 2008). In one example of a PPM (Erickson & Ditomassi, 2011), the nine components were: (1) vision and values, (2) standards of practice, (3) innovation and entrepreneurial teamwork, (4) clinical recognition and advancement, (5) research, (6) patient care delivery model, (7) collaborative decision making, (8) narrative culture, and (9) professional development. Traditional aspects of the PPM, which are often also incorporated into strategic planning, are organizational mission statements such as mission, vision, values, and philosophy. Organizational structural elements that are the foundation of a PPM are policies and procedures.



Mission Statements


Within an organization there is an established framework for management. For each organization, a characteristic collective of power and authority is vested in the managerial hierarchy. This legitimate authority, given by position, is used with the management process, management skills, and whatever resources are available to meet the organization’s goals. The elements of management and the resources available combine to form the basic framework for the management and functioning of an organization. Organizations have a mission—to produce a product or service. This goal will be expressed in mission statements and carried through into policies and procedures, all documents that form the basis for guiding standard operations. These documents are generally gathered into an overall strategic plan.


As a service industry, health care has a product. The basic product of health care is client care service, such as disease treatment or health promotion. Health may be the ultimate outcome to be achieved. An interesting question is whether the product of nursing is the same as the product of health care. Quality care is one ideal product of health care. Kramer and Schmalenberg (1988a, b) said that the product of a hospital is a quality, accessible, cost-effective service called client care. In hospitals, 90% of client care is delivered by nurses. If the product is “quality care,” valid and reliable measurement is needed to ensure that quality care is delivered and received. The idea has been presented that nursing is not a service composed of tasks but, rather, a business with a product of enhanced client outcomes and contained costs (Zander, 1992). This idea takes Drucker’s (1973) conceptualization and merges ideas about a service industry with ideas about traditional for-profit businesses. For nursing, the product is derived from the use of expertise to solve problems for clients. Similarly, the product of nursing administration relates to the use of expertise to solve problems for nurses within systems of care.


Mission, values, and vision are the glue that holds an organization together. They describe what the organization is trying to do, how to go about it, and where it is headed. This helps keep an organization on track and provides yardsticks for measuring present performance. Groups can be brought to crisis by conflicts over basic issues of mission, values, and vision. Without these agreements in place, no organization is truly viable (Adams, 2004).


Mission, vision, and values statements can be mere words on a page, or they can be “living documents” that unify an organization around a purpose. The process of development of these statements needs to begin with bringing members into basic agreement and alignment around the statements.


Using a goals-based strategic planning method, the first step is to develop a mission statement. The mission of any organization is its purpose, function, and reason it exists. Organizations exist to do something such as produce a product or deliver a service. The founders’ intentions for what they wanted to achieve by starting this organization need to be reexamined and refreshed periodically to keep the organization dynamic (Adams, 2004). For a health care organization, the mission relates to health care services—for example, client care, teaching, and research. For a nursing department’s purpose, constraints include the organization’s purpose, the state nurse practice act and other legal parameters, the context of the local community, and the directives of regulating agencies. The mission statement should be short, concise, and clear. The mission of the nursing department should mesh with the mission of the institution.


In developing a mission statement, factors such as the organization’s products, services, markets, values, public image, and activities for survival need to be considered (McNamara, 2008). In addition, the intent of the organization’s founders and its history are useful to review. Often employees are unaware of historical background. Because the mission statement needs to describe the overall purpose of the organization, the wording should be carefully crafted. It needs to be derived by a process that respects the organization’s culture. The statement needs to have sufficient description to clearly identify the purpose and scope and suggest some order of priorities (McNamara, 2008).



Vision Statements


Vision statements are designed to address the preferred future of the organization. They draw on the mission, beliefs, and environment of the organization and are positive and inspiring. Vision statements are crafted to describe the most desirable state at some future point in time. Often, one step in planning is a gap analysis of the difference between the current state and the vision (Drenkard, 2001). The advantage of vision statements are that they transcend bounded thinking; identify direction; challenge and motivate; promote loyalty, focus, and commitment; and encourage creativity. Vision statements are designed to rise above fatigue, tradition, routine, and complacency. Visioning is setting a high-level direction through turbulent times and creating a compelling picture of a desirable future state. Imagery and stories may be used to sustain the vision. Vision statements need to be vivid enough to keep the organization moving forward.



Values Statements


Core values are strongly held beliefs and priorities that guide organizational decision making. Core values are things that do not change. They are anchors or fundamentals that relate to mission and purpose and hold constant, whereas operations and business strategies change. Values drive how people truly act in organizations. They are the bridge to align how people actually behave with preferred behaviors (McNamara, 2008). Adams (2004, p. 2) stated, “Articulating values provides everyone with guiding lights, ways of choosing among competing priorities, and guidelines about how people will work together.”


One way that core values are expressed are through lists or values statements as part of a strategic plan. Another way to express values as statements is to compose a statement of philosophy. Some organizations have philosophy statements, and others use a mix of mission, vision, and values statements as a proxy for their philosophy. Both individuals and organizations can compose a statement of philosophy. For an individual, this would be an expression of personal and professional values, vision, and mission. Although difficult to do, writing a personal professional statement of philosophy is an exercise in clarity and communication.


A statement of philosophy is defined as an explanation of the systems of beliefs that determine how a mission or a purpose is to be achieved. An organization’s philosophy states the beliefs, concepts, and principles of an organization. It serves as a guide for and an explanation of actions (Poteet & Hill, 1988). The philosophy is abstract: it describes an ideal state and gives direction to achieving the purpose. It may begin with “We believe that…” For example, the system of beliefs, or philosophy, might be stated in any of the following ways:



The philosophy has implications for a nurse’s practice role. If an organization’s stated mission includes client care, teaching, and research, then all employees will be expected to be involved in all three aspects of the mission. Part of the nurse’s job will be to teach students and be involved in research. The nursing department’s philosophy should be congruent with the organization’s philosophy. The three vital components that form the core of a nursing department philosophy are the client, the nurse, and nursing practice (Poteet & Hill, 1988).


The organization’s philosophy is important to assess as it relates to one’s personal philosophy. For example, a potential employee on a job search might compare his or her own philosophy, both of nursing practice and of management, with the philosophy of an organization in which he or she might secure employment. Is there a match? For example, hospitals owned by religious organizations may prefer to hire people who share this same religious faith. If the nurse is not of that religious faith or if he or she has a prejudice or a lack of knowledge about that religious faith, it is advisable to assess personal fit with that particular organization. If some part of the philosophy is personally distasteful, it can have implications for functioning within the practice environment. For example, a specific religious tradition may still be pervasive within the organizational culture, even though the stated philosophy may say that the organization provides care to people of all faiths. That may be bothersome. One example occurs when an organization that is owned and run by a religious group opens each administrative meeting with a prayer. Another example occurs when a nurse believes in providing the total scope of public health services to clients but the organization is run by for-profit principles that dictate the provision of only those services that make a profit. Taking a job in an organization suggests an implicit agreement to cooperate with the organization’s values while at work.




Policies


A policy is a guideline that has been formalized. It directs the action for thinking about and solving recurring problems related to the objectives of the organization.


There will be specific times when it is not clear who is supposed to do something, under what circumstances it should be done, or what should be done about unusual circumstances. For example, often there are controversies about the dress code because of disagreements about the definition of what is appropriate. This occurs, for example, when the dress code says, “Nurses will come to work dressed in appropriate attire.”


Policies direct decision making and serve as guides to increase the likelihood of consistency in decisions and actions. Policies should be written, understandable, and general in nature to cover all employees. If written, they should be readily available in the same form to all employees. Policies should be reviewed during employee orientation because they indicate the organization’s intentions for goal achievement.


After institutional approval, policies need to be collected in a manual or computerized database that is indexed, classified, and easily retrievable. Policies so organized can be easily replaced with revised ones, which often become necessary in light of new environmental circumstances. Policy formulation in any organization is an ongoing core process. Hospitals will have a standing committee for the review of policies as a part of the organizational structure. Policies establish broad limits on and provide direction to decision making; yet they permit some initiative and individuality for unique circumstances.


Policies can be implied, or unwritten, if they are essentially established by patterns of decisions that have been made. In this situation, the informal policies represent an interpretation of observed behavior. For example, the organization may expect caring treatment for all clients. This expectation may not be written as a policy of the organization. However, by the decisions and disciplinary actions that occur, an employee can infer that there is a policy that will be enforced even though it is not written. However, the vast majority of policies are and should be written. Informal and unwritten policies are less desirable because they can lead to systematic bias or unfairness in their application and enforcement (Box 15-2).



BOX 15-2   Policies




Some general areas in nursing require policy formulation. These are areas in which there is confusion about the locus of responsibility and in which lack of guidance might result in the neglect, malpractice, or “malperformance” of an act necessary to the client’s welfare. For example, clear policies need to be in place about medication error reporting and follow-up. In those areas in which it is important that all persons adhere to the same pattern of decision making given a certain circumstance, a policy is necessary so that it can be used as a guideline. Also, areas pertaining to the protection of clients’ or families’ rights should have written policies. For example, the use of restraints to manage difficult clients came under scrutiny as the Omnibus Budget Reconciliation Act of 1987 (OBRA) pushed restraint-reduction strategies and created policy revisions. Other examples are policies related to “do not resuscitate” and end-of-life care. Areas involving matters of personnel management and welfare, such as vacation leave, should have written policies. In such cases, the lack of a uniform policy would be considered unfair. Many conflicts arise about the scheduling of vacations. How many people can be off at any one time? How long in advance must a vacation request be made? How is the priority for granting requests to be determined (e.g., by seniority or order of request)? The policy is the guideline for determining specific decisions.



Procedures


Procedures are step-by-step directions and methods for actions to follow in common situations. Procedures are descriptions of how to carry out an activity. They are usually written in sufficient detail to provide the information required by all persons engaging in the activity. This means that procedures should include a statement of purpose and identify who is to perform the activity. Procedures should include the steps necessary and the list of supplies and equipment needed. A procedure is a more specific guide to action than a policy statement. Procedures usually are departmentally or divisionally specific, so they will vary across an institution. They may be very detailed as to how to perform a specific procedure on a specific unit. They help achieve regularity. They are a ready reference for all personnel (Box 15-3).



BOX 15-3   Procedures




The similarities between policies and procedures are that both are a means for accomplishing goals and objectives. Both are necessary for the smooth functioning of any work group or organization. The difference between a policy and a procedure is that a policy is a general guideline for decision making about actions, whereas a procedure gives directions for actions. For example, policies about the use of restraints to manage difficult clients would indicate when such restraint use is appropriate. Procedures would cover how to apply specific devices.


A policy is a more general guide for decision making; a procedure is more like a cookbook recipe or a how-to guide giving specific directions about how to perform a certain act or function. There are legal implications to the application of policies and procedures. For example, the nurse may be held liable for failing to follow written policies and procedures. Thus it is important for nurses to be informed about the policies and procedures governing practice in an institution. In addition, both policies and procedures need regular, periodic reviews.



Healthy Work Environment


Nurse leaders and managers can create and maintain an environment that facilitates the practice of the professional nurse. Leadership is required to bring about a good environment. Three elements form the basis for the creation of a positive professional work environment: fun, hope, and trouble. Nurses can use these elements to support each other, stimulate creativity, and work together successfully (McCloskey, 1991). Another aspect of leadership and management in times of change is the creation of a healthy work environment as a nursing core value. Striving for a healthy work environment is a conscious choice. Respect is a hallmark criterion. Elements for constructing such an environment include acknowledgment of the reality of the present environment, clear behavioral expectations and standards, systems and structures to ensure that organizational changes are enduring, and a means to continually assess the health of the work environment. Bylone (2011) noted that nurses still struggle to create a healthy work environment. The six standards of a healthy work environment (American Association of Critical Care Nurses, 2005) are: skilled communication, true collaboration, effective decision making, meaningful recognition, appropriate staffing, and authentic leadership. They have direct relevance to PPMs.


Both older and newer systems and models of patient care delivery are in use. The complexity of the health care environment strongly influences organizational decisions regarding patient care. Fiscal responsibility, accountability to the consumer, and quality and safety outcomes are priorities in an environment of increasing health care costs and health care errors. The development of new models is characterized by changes in the health care climate, including costs, consumer expectations, patient characteristics, and new medical information and technology (Wolf & Greenhouse, 2007). Although all models have their advantages and disadvantages, there is no one right way to structure patient care. The appropriate care delivery model is the one that maximizes existing resources while meeting the objectives of direct and indirect patient care functions (Deutschendorf, 2003). In addition, pieces of older systems often are incorporated into new delivery models as they are developed. Therefore it is important to understand the variety of models available, both old and new. Pure nursing models (effective in less complex times) have yielded to collaborative practice and interdisciplinary approaches with the proliferation of health care provider roles, expedited care processes, and increased severity of illness.



RESEARCH NOTE




Purpose


There is a lack of consistent evidenced-based definitions regarding the elements of nursing care models and their influence on outcomes of care. The purpose of this article was to describe the prevalence of standard nursing care models in acute and intensive care units, as well as the assignment of non–unit-based personnel resources. Standard nursing care models included team, functional, primary, total patient care, patient-focused care, and case management. Forty acute care, nonfederal hospitals were selected from six different metropolitan areas, which encompassed 56 intensive care units (ICUs) and 80 adult medical and surgical units. Average daily census for each hospital was at least 99 patients. The selection of hospitals was representative of all U.S. geographical regions and included at least one large academic medical center. Data collection was achieved through staff and leadership structured interviews related to staffing deployment, roles, and care delivery models. Definitions of the elements of each patient care delivery model were identified through a comprehensive literature review.



Discussion


None of the elements of traditional care delivery models were fully implemented on any unit and were inconsistent intra-organizationally as well. Although many nurses reported that they used a primary care model, the defined elements of primary care were not evident. Although the ICUs were more likely to identify a “primary nurse,” there was a wide variation in consistent nursing/patient assignments across both ICUs and adult acute care units. Nursing personnel such as nursing assistants and licensed practical nurses/licensed vocational nurses (LPNs/LVNs) might be assigned to patients rather than tasks. Non-unit supportive personnel were not designated to specific units and were not considered to be part of unit staffing. Case management was inconsistently implemented across units in the same organization.

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Aug 7, 2016 | Posted by in NURSING | Comments Off on Professional Practice Models

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