The Importance of Professional Practice Models: Appreciating Significance
Professional nursing practice, health system value, professional practice model (PPM) integration
By the end of this chapter, the reader will be able to:
1. Describe the current context of professional nursing practice
2. Articulate how professional practice models (PPMs) contribute to health system value
3. Evaluate the preparatory steps for PPM integration
REALITIES OF PROFESSIONAL NURSING PRACTICE
RNs are practicing today in complex workplaces where financial pressures, regulation, advanced technology, looming retirements, globalism, acutely ill patients with never-ending needs, and multigenerational differences are commonplace, creating both demanding challenges and emerging opportunities. Difficulties, such as decreased resource allocation, overemphasis on routine tasks and documentation, employee disagreements, lack of support from ancillary services, compassion fatigue, and, most disheartening, uninteresting work, leave professional nurses frustrated and oftentimes yearning for alternative employment. Compounding this are the myriad organizational changes that leaders are demanding, many times without adequate evidence of their benefit.
To better understand the increasingly complex context of professional nursing practice, attention to the characteristics of individual nurses (education, credentials, unique life experiences, demographics), the characteristics of patients and families (acuity, age, life experiences, comorbidities), and the context (type of organization and its culture, how nursing is expressed and upheld, available resources, leadership, the nature of inquiry and creativity fostered, and relationships among the health care team) is warranted. These factors greatly influence professional nursing work, including its effectiveness in influencing positive patient outcomes. Although some of these factors are not under the direct control of nursing (e.g., patient characteristics), individual characteristics of nurses and how nursing is expressed and upheld in an organization are usually the purview of nursing.
Typically, some individual nursing characteristics become known during the hiring process, provided the process is thorough and can distinguish candidates who display professional behaviors, are nurturing, value lifelong learning, practice accountability, and can work together in teams from those who do not exhibit such characteristics. Once on board, individuals who tend to be more flexible, handle feedback positively, maintain their expertise, can regulate their emotions, are self-aware, and who cultivate relationships tend to perform better and are more engaged (Fujino, Tanaka, Yonemitsu, & Kawamoto, 2014; Schutte & Loi, 2014); these individuals exhibit high emotional intelligence (Goleman & Sutherland, 1996). These emotional characteristics can be influenced through ongoing continuing education, effective mentoring, specific professional development programs, and work experience; in essence, individual nurse characteristics can be molded by the context in which the nurse works (Goleman, Boyatzis, & McKee, 2013).
The expression of nursing professional practice in an organization, however, reflects how nursing is considered, conveyed, and claimed in an organization.
If nursing is considered a “profession” and its major concepts and scope are made explicit, the resultant practice will likely manifest specific values, activities, and interactions that reveal the full extent of nursing knowledge and skills.
For example, nurses who understand what concepts define their practice and who know the range of activities and interactions expected are more likely to adhere to those notions and perform accordingly. An example of this is demonstrated in a health system that distinguishes the use of the nursing process to provide holistic care that effectively meets patient and family needs, ensures that direct care nurses are engaged in practice improvement by participating in performance improvement or research councils, and enables interprofessional interactions characterized by inquiring, collaborative relationships. Such practice fosters creative patient-centered solutions. Typical performance in such a health system would be demonstrated by nursing actions, such as problem solving, analyzing, monitoring, teaching, counseling, decision making, improving, and relating, whereas fragmented, mechanistic-type work is likely minimized. When the major concepts and range of activities that comprise nursing are carefully considered, higher level professional knowledge and skills, for which nurses have been educated, may be better manifested.
These actions are conveyed to a health system through verbal and written statements, such as philosophies, clinical and system-wide policies, and marketing materials, as well as processes such as nursing representation on system-wide committees.
Conveying the scope and concepts that ground nursing practice in an organization implies written, face-to-face, formal, informal, electronic, group and individual communication and dissemination mechanisms that allow for questioning and feedback to ensure adequate appreciation of the role.
How a health system organization claims nursing professional practice is made visible through its hiring practices, performance expectations, professional development programs, and advancement criteria. Such processes, when infused with articulated nursing concepts and the full range of activities that professional nurses are educated for, tend to be reinforcing. Professional nursing practice that manifests in this manner is advocated for, defended, and rewarded, upholding the professionalism associated with nursing work. Although the context of nursing work is complex and dynamic, how it is expressed and upheld in an organization is an opportunity to create the energy for professional, interesting, and meaningful work (see Table 2.1 for a summary of these processes).
Table 2.1 Organizational Expression of Nursing Practice
Health System Processes
Nursing is thought about as a professional discipline (i.e., knowledgeable, competent, adheres to code of conduct and national standards, accountable)
Nursing activities and interactions exhibit the full extent of nursing knowledge, skills, and values
Verbal and written materials concerning nursing reflect its professional nature
Organization-wide appreciation of the professional practice of nursing
Talent acquisition, performance expectations, and advancement criteria reflect professional ideals
Professional nursing practice is defended, advocated for, and upheld at all levels of the organization
THE VALUE OF PROFESSIONAL PRACTICE MODELS
Value connotes worth or merit of something (in this case a professional practice model [PPM]) and may also be associated with significance.
Professional practice models demonstrate nursing’s contribution and project nursing’s identity in an organization. As such, they hold value to patients, nurses, the discipline, and the organization.
Patients and families directly benefit from receiving care by nurses who practice under a PPM. More specifically, they can expect more commitment to professional values, accountability, ongoing competence, continuity, nurse input and collaboration on the interprofessional team (advocating for them), and creativity. Such behaviors translate into more robust decision making through increased reliance on evidence; caring for the “whole person”; individualized and participatory activities; new ideas solicited and welcomed; and full application of nursing’s values, knowledge, and skills. Although little is known about whether PPMs actually improve patient outcomes (because few have studied this), it is rather intuitive that nurses who practice to their full extent would be a driving force in the attainment of health outcomes.
For nurses, a professional practice model depicts the major values and beliefs about nursing, identifies the parameters of nursing practice, including its responsibilities and authority for patient care, explicitly describes the systems for how nursing work is operationalized, and acknowledges expert practice.
PPMs offer nurses a way to appreciate their role expectations; facilitate a common language that is useful for communication; enable connections with patients, families, and others on the health care team; accelerate documentation; frame nursing interventions; and improve their practice. In essence, PPMs attend to the “voice of the nurse,” empowering the nurse to advocate for patients and families, fulfill societal expectations, creatively innovate, and advance.
Professional practice models support health systems by translating nursing concepts to the bedside, specifying the standards for nursing practice, enhancing communication, and reducing practice variation.
Although some practice variation may be beneficial, too much reduces effectiveness and efficiency. Take, for example, the routine of handwashing. In one Australian study using 30 nurses, the level of variation among and between nurses’ reported practices and local policies was widespread and it extended across all aspects of handwashing practices—duration and extent of handwashing, type of solution, and drying method used (Morritt et al., 2006). It was proposed that nurses made their own risk assessments based on the proximity of the procedure to the patient. Despite the fact that hand-hygiene compliance has been continually taught and reinforced among health care providers and is linked to reduced hospital acquired infections and resultant costs, compliance with hand-hygiene guidelines has remained low (Larson, 2013; Sahay, Panja, Ray, & Rao, 2010). Thus, practice variation in this case may negatively impact patient and cost outcomes.
Contrarily, carefully establishing what nursing is and how it is operationalized in an organization may improve patient outcomes (e.g., safety, clinical outcomes, and the patient experience of care) and reduce costs (length of stay, supplies, and procedures). Additionally, because nursing practice is aligned with professional values, more satisfied and engaged employees may result, adding value to both patients’ and health systems’ portfolios. Nursing leaders and hospital administrators, who facilitate resources and provide the means for integration, can embrace PPMs as a way to increase organizational value.
From a disciplinary perspective, PPMs add value by providing clarity in terms of core competencies and role accountability (e.g., delineate differences and similarities among professional, technical, and assistive roles), may improve transfer of information and collaboration within clinical teams, provide a method for evaluating performance, allow for benchmarking among similar organizations, and frame professional development programs, including credentialing and self-regulation. Such transparency informs nursing curricula, professional standards, practice improvement, and even research funding priorities.
Based on the obvious value of PPMs to patients, nurses, health systems, and the discipline, it is reasonable to assert and pursue their integration as nursing responds to the current challenges in health care. Through PPMs, an organization’s values and mission are made explicit, shaping resultant policies, including the compensation and advancement structure, resource use, the type and quality of services it offers, and ultimately the bottom line! For health care systems, that bottom line is improved patient outcomes, satisfied, engaged employees, and reasonable expenses. Committing to a PPM, however, requires an understanding of the process, including appropriate preliminary work, to satisfy the conditions for successful integration.
THE PROCESS OF PROFESSIONAL PRACTICE MODEL INTEGRATION
Just as the management of patients and families is moving toward a coordinated continuum of care, nursing is shifting its thinking from separated, geographic settings and task-oriented procedural functions to interdependent, coordinated professionals working together over time to meet unique, yet ultimately common, goals. Integration has been defined as “the collaboration and linkages between and across organizational functions as well as organizational partners, including customers and suppliers” (Teixeira, Koufteros, & Peng, 2012, p. 73). This definition implies a rich network of collaboration and information sharing among individuals and departments, increasing transparency and feedback and the likelihood of mutual problem solving. It also connotes better performance in terms of quality and innovation. Successful internal integration helps create unity among employees and alignment with the organization’s mission. External integration refers to the collaborative involvement of others, such as academicians, other health systems, customers (patients and families), and even vendors, where trust, commitment, and information sharing become the norm.
Integration of PPMs establishes harmony among nurses, nurse leaders, various departments, other health care providers, patients and families, and the overall health system, provided it is successful.