JONA Volume 45, Number 1, pp 43-49 Copyright B 2015 Wolters Kluwer Health | Lippincott Williams & Wilkins
THE JOURNAL OF NURSING ADMINISTRATION
Developing, Implementing, and Evaluating a Professional Practice Model Roberta Basol, MA, RN, NE-BC Amy Hilleren-Listerud, DNP, RN, ACNS-BC, CBN, PCCN Linda Chmielewski, MS, RN, NEA-BC This article describes how The Compass, a professional practice model (PPM), was developed through clinical nurse involvement, review of literature, expert opinion, and an innovative schematic. Implementation was supported through a dynamic video account of a patient story, interwoven with The Compass. Postproject evaluation of PPM integration demonstrates opportunities for professional nursing development and future planning. Magnet designation calls for organizations to provide a description, with supporting evidence, of the development and ongoing evaluation of a nursing professional practice model (PPM), including clinical nurse (CN) involvement.1 At St Cloud Hospital, a PPM committee composed of CNs, nursing directors, educators, case managers, and advanced practice nurses was formed to develop and guide the integration of a PPM into nursing practice. Located in central Minnesota, St Cloud Hospital has been Magnet designated 3 times. Licensed for 489 beds, the regional medical center has 26 000 inpatient admissions and 255 000 outpatient visits annually, with patient care provided and coordinated by 1 500 nurses. A
Author Affiliations: Care Center Director (Ms Basol), Intensive Care/Surgical Care and Clinical Practice; Clinical Nurse Specialist (Dr Hilleren-Listerud), Surgical Care Unit; and Vice President, Hospital Operations/Chief Nursing Officer (Ms Chmielewski), St Cloud Hospital, CentraCare Health, St Cloud, Minnesota. The authors declare no conflicts of interest. Correspondence: Ms Basol, St Cloud Hospital, 1406 6th Ave N, St Cloud, MN 56303 ([email protected]). Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal’s Web site (www.jonajournal.com). DOI: 10.1097/NNA.0000000000000153
JONA Vol. 45, No. 1 January 2015
Background Prior to the development and implementation of The Compass: St Cloud Hospital’s Nursing PPM (The Compass), tactics had been outlined in the nursing strategic plan to enhance the organization’s nursing professional practice environment. Those tactics included focusing on relationship-based care, healthy work environment, transformational leadership, shared governance, and nurse sensitive indicators. In addition, nursing departments developed professional nursing standards consistent with the American Nurses Association’s Nursing: Scope and Standards of Practice.2 With these initiatives having served as the foundation for The Compass PPM, a comprehensive review of the literature was conducted. Review of Literature A PPM supports the articulation of contributions to practice from the profession.3 Professional practice models are systems consisting of structures, processes, and values that support registered nursing’s control over the delivery of nursing care and the environment in which care is delivered.4 Five subsystems are recommended in a PPM: professional values, professional relationships, a care delivery model, management or governance, and professional recognition and rewards.4,5 Common in many models is the inclusion of the nursing mission, vision, and values and components and subcomponents specific to high-quality professional practice.6 Models may include philosophy statements regarding patient care, education, research, and quality contributions, as well as standards, which are the practical application of both values and philosophies.7 Donabedian’s structure, process, and outcomes model has served as a common framework for creating an organization-specific PPM
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Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
for nursing.8 Other frameworks cited in the literature supporting PPMs include The Quality Caring Model,9 shared governance,10 the Synergy Professional Practice Model,11 and Careful Nursing.12 In addition to being transferrable to nurses in a variety of settings, development and integration of a PPM require participation from nurses at all levels in order to be one that nurses can understand and articulate.13 A PPM provides a framework for the achievement of exemplary clinical outcomes.3 With a well-designed framework, nurses feel connected to the context of relationships with patients, personal practice, other healthcare providers, other nurses, and the organization.3 To assess the integration of a PPM to nursing practice, Magnet-recognized organizations evaluate PPM assimilation as a component of their documentation. Evaluation through a formal assessment is an efficient way to appraise staff involvement in the organization’s PPM.14 Responses can reveal level of involvement at a unit level and provide important feedback to leaders.14 Measuring PPM integration allows organizations to establish trends and identify opportunities to transform and improve practice.3 Evaluation of a PPM has been described using both internal and external methodologies. Internal evaluation provides an assessment of organizational characteristics important to clinician satisfaction, trends key information, provides feedback on strategic goals, and identifies opportunities to improve practice settings. External validation may be reflected through Magnet designation.3 Measurement tools should assess components of specific PPMs. The reliability of utilizing existing tools to measure PPM integration is not well established in literature.14 This lack of comprehensive PPM measurement tools is likely due to the complex and individualized nature of conceptualizing and quantifying professional nursing practice.15 Utilizing a measurement tool specific to an organization’s PPM, once validated, has the benefit of being both comprehensive and reflective of actual professional nursing practice within the organization.16
Development of the Professional Practice Model A review of existing PPMs was conducted to determine if there was a PPM that would be a good fit for the organization. The committee determined the selected PPMs did not reflect nursing practice at our facility and subsequently began to construct a PPM specific to the organization. The committee attended a presentation by Gail Wolf, PhD, RN, FAAN, past Magnet Commission Chair and a published expert on PPMs, which served as a catalyst for the development of the hospital’s PPM.
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Dr Wolf’s presentation associated PPMs with words such as journey, direction, course, and navigate. Those words resonated with the committee, prompting the idea to incorporate compass symbolism. The Compass: St Cloud Hospital’s Nursing PPM, as it is known today, began to emerge. The Compass At the center of The Compass: Nursing’s PPM is patientand family-centered care, which is strongly embedded within the organization. The hospital’s mission encircles the center, displaying the 6 elements of the mission acronym CHRIST: collaboration, hospitality, respect, integrity, service, and trust. Each word is separated by a Benedictine cross representing the Catholic heritage of the hospital. Further encircling The Compass are the 4 key components of the organization values: quality, safety, value, and service. The 4 cardinal points of The Compass represent the core PPM framework components found in literature.4 Care delivery is identified as nursing care delivery (North); recognition, reward, development as exemplary professional practice (East); management governance as shared governance (South); and professional relationships as working relationships (West) (Figure 1). Each of the core components contains subcomponents to further define the model (Table 1). Introduction of The Compass The PPM was formally introduced to RNs using interactive, media-rich education sessions to ensure understanding of how the model applies to professional practice nursing. The goal of the education sessions was to convey to RNs the purpose and value of a PPM, inspire belief in The Compass, and begin to weave the model into the fabric of day-to-day professional nursing practice. The mandatory education utilized a PowerPoint presentation on the complexity of nursing practice, the concept of models in relation to nursing practice, the definition of a PPM, and an introduction to The Compass. Through The Compass education, nurses learned the motivation to use a compass as the symbolic representation of the PPM. The Compass demonstrates how nurses are challenged to navigate through an unknown course in healthcare. Compasses, which are driven by magnet forces, give direction and support navigation. The Compass PPM is used to help nurses set a course, guide the journey, and lead into the future. A strong element in the nursing education was viewing a video called Lynn’s Journey, which illustrated The Compass through a patient’s story. Implementation of The Compass The use of the patient story (see Video, Supplemental Digital Content 1, an excerpt of Lynn’s Journey,
JONA Vol. 45, No. 1 January 2015
Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
Figure 1. The Compass: St Cloud Hospital’s nursing PPM.
http://links.lww.com/JONA/A374) contributed significantly to the successful implementation of the PPM. Narrated by the chief nursing officer (CNO), the video described The Compass as a guide for how nurses practice, collaborate, communicate, and develop professionally. The video illuminated how the PPM defines what is important to nurses and how it guides current and future nursing practice demonstrated by an actual patient case study. The video opens with Lynn’s arrival to the hospital by helicopter, to undergo immediate lifesaving surgery for repair of a ruptured abdominal aortic aneurysm. He was critically ill for several days, receiving mechanical ventilation and hemodynamic support. Following a lengthy hospital stay and challenging course of recovery, Lynn was discharged with home care and dialysis. After a few months, Lynn’s renal function returned to baseline. Lynn’s Journey transpired through many aspects of the healthcare continuum, from prehospital, to acute care, progressing to outpatient dialysis. Lynn’s story was brought to life through video vignettes of nurses, physicians, respiratory therapists, social workers, and other members of Lynn’s healthcare team describing their roles in Lynn’s care and recovery. The CNO related
JONA Vol. 45, No. 1 January 2015
the work and experiences to components of The Compass and to the practice of nursing. For example, an ICU nurse explained nursing care delivery as providing 1-to-1 care for Lynn, the comprehensiveness of her assessment in adherence with standards and practice, and how case management supported Lynn’s transition out of the ICU. During the working relationship component, a surgical care unit nurse shared how her collaborative practice with home care and dialysis prepared Lynn to go home. The RN also described the special connection she had established with Lynn and his family through relationship-based care principles. Postpresentation feedback regarding the video was overwhelmingly positive, and participants appreciated the use of the video as a way to relate The Compass to their practice. Integration of The Compass PPM integration efforts continued beyond the initial education sessions and Lynn’s Journey video. PPM integration is a complex organizational change requiring expert leadership.17 Best leadership practices for PPM integration into daily life include providing credit and acknowledgement for practice at a higher level,
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Table 1. Components and Subcomponents of The Compass Mission Statement As a Catholic regional hospital, we improve the health and quality of life for the people we serve in a manner that reflects the healing mission of Jesus. Vision Statement Through our Catholic healing ministry, St Cloud Hospital will be the leader in Minnesota for quality, safety, service, and value. Core Values Collaboration, hospitality, respect, integrity, service, trusteeship Patient- and Family-Centered Care Nursing Care Delivery & Patient satisfaction
& Coordination of care & Case management & Nursing provision of patient care & Nursing Scope and Standards of Nursing Practice & Code of Ethics & State Nurse Practice Act
& & & & & & & & &
Exemplary Professional Practice
Shared Governance
Working Relationships
Evidence-based practice Nursing research Innovation Nursing-sensitive indicators Clinical Ladder Program Professional growth Autonomy Magnet designation Performance improvement
& Shared governance & Transformational leadership & Staff engagement
& Relationship-based care & Healthy work environment & Collaborative practice & Just culture & Coaching and mentoring & Recognition & Community outreach
ensuring visibility of the model through leadership practices, modeling the values, shifting nurses from a task-completion mindset to problem-solving, and incorporating evidence-based practice and research in nursing practice.17 Additional methods for PPM integration recommended developing common language that showcases the major themes of a PPM, integrating the common language of the model into communication vehicles, connecting the PPM to annual performance reviews, performing interval gap analysis, and using a reward and recognition system based on the model.17 To ensure visibility, framed pictures of the model were prominently displayed in patient care and public areas. A brochure was given to each nurse containing the entire content of The Compass (see Document, Supplemental Content 2, http://links.lww.com/JONA/A375). To support communication and common language, The Compass was presented to key hospital leadership and nursing committees, as well as executive and physician leadership. The Compass was incorporated into printed and electronic hospital newsletters and agendas, and nurse leaders added The Compass to unit newsletters and agendas. Performance expectations pertaining to The Compass were added to job descriptions, orientation checklists, and performance appraisals. The surgical care units created The Compass Award, given to a nurse who displays the professional attributes of the model.
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The clinical ladder program was revised to use The Compass as the framework for the clinical ladder criteria. The nursing strategic plan structure was modified to reflect the components of The Compass, with thoughtful consideration to strengthen each component. The measurement of how well The Compass was integrated was accomplished through a quality improvement study. Evaluation Magnet hospitals must create and test models of professional practice for nurses.1 A study was conducted to evaluate application of The Compass in professional nursing practice using an organizationspecific measurement tool. The study’s measurement tool named The Compass Assessment Tool (COMPAT) (see Document, Supplemental Digital Content 3, http://links.lww.com/JONA/A376) was designed to correlate nurses’ perception of professional nursing practice with the components of The Compass: patientand family-centered care, nursing care delivery, exemplary professional practice, shared governance, and working relationships. Twenty questions were developed to represent the application of The Compass components and subcomponents, using a consistent interval measurement for each question. Two focus groups composed of 12 nurse leaders from the organization reviewed the survey to establish face and content validity of the COMPAT. The
JONA Vol. 45, No. 1 January 2015
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focus groups were facilitated by an affiliated university faculty to minimize bias. With confirmed face and content validity of 0.88, the COMPAT was administered to 9 nurses in a pilot unit. Reliability was calculated to be 0.92. The study surveyed a convenience sample of 1253 RNs before Compass implementation and 1319 RNs after Compass implementation. Nurse names were obtained from the hospital’s human resource database following institutional review board approval. Consent to participate was implied by voluntary participation, requested via organization e-mail. Participants were instructed to select the best answer as it pertained to all RNs in their unit, department, or area of nursing practice. For example, to measure autonomy, nurses were asked, ‘‘What percentage of RNs in my unit or area of practice consistently demonstrate autonomy by making decisions that are individual and patient centered within the context of a multidisciplinary approach?’’ To measure integration of the coaching and mentoring component of The Compass, the COMPAT asked, ‘‘What percentage of RNs in my area take a personal interest in actively coaching and mentoring new RNs to foster growth and development and achieve their full potential?’’ Participants selected from one of the following responses: less than 10%, approximately 25%, approximately 50%, approximately 75%, and greater than 90% (see Document, Supplemental Digital Content 3, http://links.lww.com/JONA/A376). Demographic data, including unit or area of practice; age, years as a nurse at the hospital, degree, certifica-
tion, position, and primary shift, were also collected in the COMPAT. Survey return rates were 45% in the before Compass implementation period and 30% after Compass implementation. Document, Supplemental Digital Content 4, provides a summary of the demographic characteristics of the subjects (http://links.lww.com/JONA/A378). The COMPAT fixed interval scale was converted to a numeric value: 1 (G10%), 2 (approximately 25%), 3 (approximately 50%), 4 (approximately 75%), or 5 (990%). The overall grand mean of the COMPAT at the hospital level was calculated at 3.34 in the preCompass implementation period and increased to 3.74 in the post-Compass implementation period. PPM integration into professional nursing practice was measured by calculating mean and z scores by both PPM component-specific question and department. Department and question results were divided into 1 of 3 categories; high, medium, or low. The categories were defined as 2 SEs above the mean (high), T2 SEs from the mean (medium), and 2 SEs below the mean (low). Each component-specific question and department were placed into a category based on the result. The highest mean score was standards of practice (4.40 pre- and 4.61 post-Compass implementation), and the lowest mean score was research (1.83 pre- and 2.02 post-Compass implementation) on a 1- to 5-point scale. Table 2 provides a summary of componentspecific question results, including enculturation level, mean, and z scores. The department pre-Compass
Table 2. Enculturation Level, Mean, and z Score by Component Pre-Compass Implementation
Coordination of care/case management Provision of patient care Standards of professional performance Standards of practice Evidence-based practice Research Innovation Nursing-sensitive indicators Professional growth Autonomy Performance improvement Shared governance Transformational leadership Relationship-based care Healthy work environment Culture of safety Coaching and mentoring Collaboration Recognition Community outreach
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Post-Compass Implementation
Mean
z Score
Enculturation Level
Mean
z score
Enculturation level
4.20 2.42 3.81 4.40 2.54 1.83 2.52 3.23 3.80 4.18 3.17 2.88 2.81 4.13 3.84 3.98 3.49 4.16 3.52 1.92
18.06 j19.30 9.78 22.26 j16.97 j31.79 j17.29 j2.31 9.59 17.57 j3.57 j9.72 j11.11 16.52 10.51 13.56 3.20 17.13 3.73 j29.85
High Low High High Low Low Low Low High High Low Low Low High High High High High High Low
4.37 3.24 4.22 4.61 4.23 2.02 3.05 3.56 3.96 4.40 3.30 3.47 3.31 4.45 4.13 4.31 3.79 4.44 3.82 2.26
11.50 j6.63 10.07 22.70 10.37 j32.08 j10.76 j2.67 4.33 15.71 j6.44 j4.06 j6.58 16.58 7.66 12.38 0.91 17.03 1.44 j25.21
High Low High High High Low Low Low High High Low Low Low High High High Med High Med Low
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Table 3. Enculturation Level, Mean, z Score by Department Pre-Compass Implementation
Rehabilitation Home care/hospice Pediatrics/pediatric intensive care/pediatric progressive care/neonatal ICU Surgery Oncology Intensive care unit Telemetry Patient care support/float pool Cardiac care unit Cancer center: chemotherapy/infusion, radiation oncology Adult and/or adolescent mental health Medical care units/medical progressive care unit Post anesthesia care unit Center for surgical care Dialysis, acute and chronic Surgical care/surgical progressive care unit Bone and joint center Neurosciences/neuro progressive care unit Family birthing center Emergency trauma center
Post-Compass Implementation
n
Mean z Score Enculturation level
n
Mean z Score Enculturation level
10 12 34
3.26 3.91 3.57
NA 9 6.22
NA High High
11 8 20
3.79 3.82 3.88
0.31 NA 0.76
Medium NA Medium
23 38 29 40 28 14 13
3.59 3.55 3.48 3.43 3.43 3.42 3.40
5.61 5.53 3.47 2.31 2.11 1.28 0.92
High High High High High High Medium
14 15 28 15 20 5 8
3.69 4.14 3.73 3.58 3.41 3.93 3.70
0.05 1.65 0.24 j0.26 j0.88 NA NA
Medium High Medium Medium Medium NA NA
20 62
3.37 3.35
0.56 0.30
Medium Medium
10 38
3.77 3.69
NA 0.12
NA Medium
14 19 15 59 23 24 47 21
3.34 j0.08 3.28 j1.24 3.19 j2.71 3.26 j3.14 3.11 j5.11 3.03 j6.94 3.07 j8.74 2.74 j12.75
Medium Low Low Low Low Low Low Low
11 15 17 20 13 18 16 11
3.70 3.49 3.77 3.58 3.84 4.05 2.96 3.23
0.09 j0.45 0.3 j0.33 0.51 1.35 j1.98 j1.08
Medium Medium Medium Medium Medium High Low Low
Abbreviation: NA = not applicable, G11 survey respondents.
implementation highest mean score was home care/ hospice (3.91), and the highest post-Compass implementation mean score was from oncology (4.14). Table 3 displays a summary of department-specific results, again calculating enculturation level, mean, and z scores. Correlations between pre- and post-Compass component integration were calculated using t tests (Table 4). A P G 0.01 was considered significant. Each component revealed an increase in mean score. All components demonstrated a statistically significant difference pre- and post-Compass implementation, with the exception of coordination of care/case management and performance improvement. The evaluation method supported a process to measure the impact of integration of The Compass. Conclusion The process of development, implementation, and evaluation of The Compass contributed to our 3rd Magnet designation. Through CN involvement, use of the literature, expert opinion, and innovative, creative design and implementation, The Compass PPM has become extremely important in professional nursing practice at St Cloud Hospital. The PPM describes how nurses practice, collaborate, communicate, and develop professionally. It defines what is important to nurses and drives current and future nursing practice.Through
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Table 4. Correlations
Coordination of care/case management Provision of patient care Standards of professional performance Standards of practice Evidence based practice Research Innovation Nursing-sensitive indicators Professional growth Autonomy Performance improvement Shared governance Transformational leadership Relationship-based care Healthy work environment Culture of safety Coaching and mentoring Collaboration Recognition Community outreach
Mean
Independent 2-Sample t Test (Unequal Sample Sizes, Equal Variance)
Pre Post
P
4.20 4.37
0.04
2.42 3.24 3.81 4.22
G0.01 G0.01
4.40 2.54 1.83 2.52 3.23 3.80 4.18 3.17 2.88 2.81
4.61 4.23 2.02 3.05 3.56 3.96 4.40 3.30 3.47 3.31
G0.01 G0.01 G0.01 G0.01 G0.01 G0.01 G0.01 0.09 G0.01 G0.01
4.13 3.84 3.98 3.49 4.16 3.52 1.92
4.45 4.13 4.31 3.79 4.44 3.82 2.26
G0.01 G0.01 G0.01 G0.01 G0.01 G0.01 G0.01
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the PPM, optimal patient outcomes are achieved. Future evaluation measurement will guide nursing strategic plans and strengthen PPM integration. During the Magnet designation process, St Cloud Hospital received an exemplary professional practice (EP1 source of evidence) report. Magnet appraisers found The Compass ‘‘visible, palpable, and threaded throughout all aspects of the organization.’’ They noted unsolicited comments from CNs about how the model informs and influences nursing practice. The video, Lynn’s Journey, was identified as an exemplary example of bringing the conceptual framework to life in a way that all can be related to and understood for all nursing staff. The development, implementation, and evaluation of The Compass successfully enhanced professional nursing practice and positioned the orga-
nization for nursing’s future. As stated by the CNO, ‘‘Guided by our Compass, the nursing excellence journey continues.’’
Acknowledgments The authors thank the following contributors to the development of The Compass: St Cloud Hospital’s Nursing PPM. Through their love for nursing and commitment to professional practice, The Compass was created: Laurie Annett, BSN, RN; Chelsie Bakken, MBA, RN; Deb Eisenstadt, MSN, RN; Mary Leyk, MSN, RN; Tiffany Omann-Bidinger, BSN, RN; Diane Pelant, BSN, RN; Joanne Reinhart, RN; Joyce Salzer, RN; Mary Schimnich, RN; Marian Seliski, BSN, RN; Kirsten Skillings, MA, RN, CNS; and Kate VanBuskirk, BSN, RN.
References 1. Evidence submission for applicants. In: 2014 Magnet Application Manual. Silver Spring, MD: American Nurses Credentialing Center; 2013:41-43. 2. Nursing: Scope and Standards of Practice. 2nd ed. Silver Spring, MD: American Nurses Association; 2010. 3. Ives Erickson, Ditomassi M. Professional practice model: strategies for translating models into practice. Nurs Clin North Am. 2011; 46(1):35-44. 4. Hoffart N, Woods C. Elements of a nursing professional practice model. J Prof Nurs. 1996;12(6):354-364. 5. Wolf G, Greenhouse P. Blueprint for design: creating models that direct change. J Nurs Adm. 2007;37(9):381-387. 6. Jost S, Rich V. Transformation of a nursing culture through actualization of a nursing professional practice model. Nurs Adm Q. 2010;34(1):30-40. 7. Erickson J, Ditomassi M. The professional practice model: a tool for articulating nursing practice. Creat Nurs. 1998;4(4): 12-14. 8. Miles K, Vallish R. Creating a personalized professional practice framework for nursing. Nurs Econ. 2010;28(3):171. 9. Edmundson E. The quality caring nursing model: a journey to selection and implementation. J Pediatr Nurs. 2012;27(4): 411-415.
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10. Latta L, Davis-Kirsch S. Developing a robust professional practice model using a shared governance approach. J Pediatr Nurs. 2011;26(6):580-585. 11. MacPhee M, Wardrop A, Campbell C, Wejr P. The Synergy professional practice model and its patient characteristics tool: a staff empowerment strategy. Nurs Leadersh. 2011;24(3):42-56. 12. Meehan T. The careful nursing philosophy and professional practice model. J Clin Nurs. 2012;21(19/20):2905-2916. 13. Berger J, Conway S, Beaton K. Developing and implementing a nursing professional practice model in a large health system. J Nurs Adm. 2012;42(3):170-175. 14. Hitchings K, Capuano T, Bokovoy J, Houser J. Development of a reliable and valid organization-specific professional practice assessment tool. Nurs Adm Q. 2010;34(1):61-71. 15. Ditomassi M. A multi-instrument evaluation of the professional practice environment. J Nurs Adm. 2012;42(5):266-272. 16. Hitchings K, Capuano T, Bokovoy J, Houser J. A validated, model-specific tool to measure the developmental stage of shared governance, professional practice model. Pa Nurse. 2005;60(4): 22-23. 17. Storey S, Linden E, Fisher M. Showcasing leadership exemplars to propel professional practice model implementation. J Nurs Adm. 2008;38(3):138-142.
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THE JOURNAL OF NURSING ADMINISTRATION
Developing, Implementing, and Evaluating a Professional Practice Model Roberta Basol, MA, RN, NE-BC Amy Hilleren-Listerud, DNP, RN, ACNS-BC, CBN, PCCN Linda Chmielewski, MS, RN, NEA-BC This article describes how The Compass, a professional practice model (PPM), was developed through clinical nurse involvement, review of literature, expert opinion, and an innovative schematic. Implementation was supported through a dynamic video account of a patient story, interwoven with The Compass. Postproject evaluation of PPM integration demonstrates opportunities for professional nursing development and future planning. Magnet designation calls for organizations to provide a description, with supporting evidence, of the development and ongoing evaluation of a nursing professional practice model (PPM), including clinical nurse (CN) involvement.1 At St Cloud Hospital, a PPM committee composed of CNs, nursing directors, educators, case managers, and advanced practice nurses was formed to develop and guide the integration of a PPM into nursing practice. Located in central Minnesota, St Cloud Hospital has been Magnet designated 3 times. Licensed for 489 beds, the regional medical center has 26 000 inpatient admissions and 255 000 outpatient visits annually, with patient care provided and coordinated by 1 500 nurses. A
Author Affiliations: Care Center Director (Ms Basol), Intensive Care/Surgical Care and Clinical Practice; Clinical Nurse Specialist (Dr Hilleren-Listerud), Surgical Care Unit; and Vice President, Hospital Operations/Chief Nursing Officer (Ms Chmielewski), St Cloud Hospital, CentraCare Health, St Cloud, Minnesota. The authors declare no conflicts of interest. Correspondence: Ms Basol, St Cloud Hospital, 1406 6th Ave N, St Cloud, MN 56303 ([email protected]). Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal’s Web site (www.jonajournal.com). DOI: 10.1097/NNA.0000000000000153
JONA Vol. 45, No. 1 January 2015
Background Prior to the development and implementation of The Compass: St Cloud Hospital’s Nursing PPM (The Compass), tactics had been outlined in the nursing strategic plan to enhance the organization’s nursing professional practice environment. Those tactics included focusing on relationship-based care, healthy work environment, transformational leadership, shared governance, and nurse sensitive indicators. In addition, nursing departments developed professional nursing standards consistent with the American Nurses Association’s Nursing: Scope and Standards of Practice.2 With these initiatives having served as the foundation for The Compass PPM, a comprehensive review of the literature was conducted. Review of Literature A PPM supports the articulation of contributions to practice from the profession.3 Professional practice models are systems consisting of structures, processes, and values that support registered nursing’s control over the delivery of nursing care and the environment in which care is delivered.4 Five subsystems are recommended in a PPM: professional values, professional relationships, a care delivery model, management or governance, and professional recognition and rewards.4,5 Common in many models is the inclusion of the nursing mission, vision, and values and components and subcomponents specific to high-quality professional practice.6 Models may include philosophy statements regarding patient care, education, research, and quality contributions, as well as standards, which are the practical application of both values and philosophies.7 Donabedian’s structure, process, and outcomes model has served as a common framework for creating an organization-specific PPM
43
Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
for nursing.8 Other frameworks cited in the literature supporting PPMs include The Quality Caring Model,9 shared governance,10 the Synergy Professional Practice Model,11 and Careful Nursing.12 In addition to being transferrable to nurses in a variety of settings, development and integration of a PPM require participation from nurses at all levels in order to be one that nurses can understand and articulate.13 A PPM provides a framework for the achievement of exemplary clinical outcomes.3 With a well-designed framework, nurses feel connected to the context of relationships with patients, personal practice, other healthcare providers, other nurses, and the organization.3 To assess the integration of a PPM to nursing practice, Magnet-recognized organizations evaluate PPM assimilation as a component of their documentation. Evaluation through a formal assessment is an efficient way to appraise staff involvement in the organization’s PPM.14 Responses can reveal level of involvement at a unit level and provide important feedback to leaders.14 Measuring PPM integration allows organizations to establish trends and identify opportunities to transform and improve practice.3 Evaluation of a PPM has been described using both internal and external methodologies. Internal evaluation provides an assessment of organizational characteristics important to clinician satisfaction, trends key information, provides feedback on strategic goals, and identifies opportunities to improve practice settings. External validation may be reflected through Magnet designation.3 Measurement tools should assess components of specific PPMs. The reliability of utilizing existing tools to measure PPM integration is not well established in literature.14 This lack of comprehensive PPM measurement tools is likely due to the complex and individualized nature of conceptualizing and quantifying professional nursing practice.15 Utilizing a measurement tool specific to an organization’s PPM, once validated, has the benefit of being both comprehensive and reflective of actual professional nursing practice within the organization.16
Development of the Professional Practice Model A review of existing PPMs was conducted to determine if there was a PPM that would be a good fit for the organization. The committee determined the selected PPMs did not reflect nursing practice at our facility and subsequently began to construct a PPM specific to the organization. The committee attended a presentation by Gail Wolf, PhD, RN, FAAN, past Magnet Commission Chair and a published expert on PPMs, which served as a catalyst for the development of the hospital’s PPM.
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Dr Wolf’s presentation associated PPMs with words such as journey, direction, course, and navigate. Those words resonated with the committee, prompting the idea to incorporate compass symbolism. The Compass: St Cloud Hospital’s Nursing PPM, as it is known today, began to emerge. The Compass At the center of The Compass: Nursing’s PPM is patientand family-centered care, which is strongly embedded within the organization. The hospital’s mission encircles the center, displaying the 6 elements of the mission acronym CHRIST: collaboration, hospitality, respect, integrity, service, and trust. Each word is separated by a Benedictine cross representing the Catholic heritage of the hospital. Further encircling The Compass are the 4 key components of the organization values: quality, safety, value, and service. The 4 cardinal points of The Compass represent the core PPM framework components found in literature.4 Care delivery is identified as nursing care delivery (North); recognition, reward, development as exemplary professional practice (East); management governance as shared governance (South); and professional relationships as working relationships (West) (Figure 1). Each of the core components contains subcomponents to further define the model (Table 1). Introduction of The Compass The PPM was formally introduced to RNs using interactive, media-rich education sessions to ensure understanding of how the model applies to professional practice nursing. The goal of the education sessions was to convey to RNs the purpose and value of a PPM, inspire belief in The Compass, and begin to weave the model into the fabric of day-to-day professional nursing practice. The mandatory education utilized a PowerPoint presentation on the complexity of nursing practice, the concept of models in relation to nursing practice, the definition of a PPM, and an introduction to The Compass. Through The Compass education, nurses learned the motivation to use a compass as the symbolic representation of the PPM. The Compass demonstrates how nurses are challenged to navigate through an unknown course in healthcare. Compasses, which are driven by magnet forces, give direction and support navigation. The Compass PPM is used to help nurses set a course, guide the journey, and lead into the future. A strong element in the nursing education was viewing a video called Lynn’s Journey, which illustrated The Compass through a patient’s story. Implementation of The Compass The use of the patient story (see Video, Supplemental Digital Content 1, an excerpt of Lynn’s Journey,
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Figure 1. The Compass: St Cloud Hospital’s nursing PPM.
http://links.lww.com/JONA/A374) contributed significantly to the successful implementation of the PPM. Narrated by the chief nursing officer (CNO), the video described The Compass as a guide for how nurses practice, collaborate, communicate, and develop professionally. The video illuminated how the PPM defines what is important to nurses and how it guides current and future nursing practice demonstrated by an actual patient case study. The video opens with Lynn’s arrival to the hospital by helicopter, to undergo immediate lifesaving surgery for repair of a ruptured abdominal aortic aneurysm. He was critically ill for several days, receiving mechanical ventilation and hemodynamic support. Following a lengthy hospital stay and challenging course of recovery, Lynn was discharged with home care and dialysis. After a few months, Lynn’s renal function returned to baseline. Lynn’s Journey transpired through many aspects of the healthcare continuum, from prehospital, to acute care, progressing to outpatient dialysis. Lynn’s story was brought to life through video vignettes of nurses, physicians, respiratory therapists, social workers, and other members of Lynn’s healthcare team describing their roles in Lynn’s care and recovery. The CNO related
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the work and experiences to components of The Compass and to the practice of nursing. For example, an ICU nurse explained nursing care delivery as providing 1-to-1 care for Lynn, the comprehensiveness of her assessment in adherence with standards and practice, and how case management supported Lynn’s transition out of the ICU. During the working relationship component, a surgical care unit nurse shared how her collaborative practice with home care and dialysis prepared Lynn to go home. The RN also described the special connection she had established with Lynn and his family through relationship-based care principles. Postpresentation feedback regarding the video was overwhelmingly positive, and participants appreciated the use of the video as a way to relate The Compass to their practice. Integration of The Compass PPM integration efforts continued beyond the initial education sessions and Lynn’s Journey video. PPM integration is a complex organizational change requiring expert leadership.17 Best leadership practices for PPM integration into daily life include providing credit and acknowledgement for practice at a higher level,
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Table 1. Components and Subcomponents of The Compass Mission Statement As a Catholic regional hospital, we improve the health and quality of life for the people we serve in a manner that reflects the healing mission of Jesus. Vision Statement Through our Catholic healing ministry, St Cloud Hospital will be the leader in Minnesota for quality, safety, service, and value. Core Values Collaboration, hospitality, respect, integrity, service, trusteeship Patient- and Family-Centered Care Nursing Care Delivery & Patient satisfaction
& Coordination of care & Case management & Nursing provision of patient care & Nursing Scope and Standards of Nursing Practice & Code of Ethics & State Nurse Practice Act
& & & & & & & & &
Exemplary Professional Practice
Shared Governance
Working Relationships
Evidence-based practice Nursing research Innovation Nursing-sensitive indicators Clinical Ladder Program Professional growth Autonomy Magnet designation Performance improvement
& Shared governance & Transformational leadership & Staff engagement
& Relationship-based care & Healthy work environment & Collaborative practice & Just culture & Coaching and mentoring & Recognition & Community outreach
ensuring visibility of the model through leadership practices, modeling the values, shifting nurses from a task-completion mindset to problem-solving, and incorporating evidence-based practice and research in nursing practice.17 Additional methods for PPM integration recommended developing common language that showcases the major themes of a PPM, integrating the common language of the model into communication vehicles, connecting the PPM to annual performance reviews, performing interval gap analysis, and using a reward and recognition system based on the model.17 To ensure visibility, framed pictures of the model were prominently displayed in patient care and public areas. A brochure was given to each nurse containing the entire content of The Compass (see Document, Supplemental Content 2, http://links.lww.com/JONA/A375). To support communication and common language, The Compass was presented to key hospital leadership and nursing committees, as well as executive and physician leadership. The Compass was incorporated into printed and electronic hospital newsletters and agendas, and nurse leaders added The Compass to unit newsletters and agendas. Performance expectations pertaining to The Compass were added to job descriptions, orientation checklists, and performance appraisals. The surgical care units created The Compass Award, given to a nurse who displays the professional attributes of the model.
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The clinical ladder program was revised to use The Compass as the framework for the clinical ladder criteria. The nursing strategic plan structure was modified to reflect the components of The Compass, with thoughtful consideration to strengthen each component. The measurement of how well The Compass was integrated was accomplished through a quality improvement study. Evaluation Magnet hospitals must create and test models of professional practice for nurses.1 A study was conducted to evaluate application of The Compass in professional nursing practice using an organizationspecific measurement tool. The study’s measurement tool named The Compass Assessment Tool (COMPAT) (see Document, Supplemental Digital Content 3, http://links.lww.com/JONA/A376) was designed to correlate nurses’ perception of professional nursing practice with the components of The Compass: patientand family-centered care, nursing care delivery, exemplary professional practice, shared governance, and working relationships. Twenty questions were developed to represent the application of The Compass components and subcomponents, using a consistent interval measurement for each question. Two focus groups composed of 12 nurse leaders from the organization reviewed the survey to establish face and content validity of the COMPAT. The
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focus groups were facilitated by an affiliated university faculty to minimize bias. With confirmed face and content validity of 0.88, the COMPAT was administered to 9 nurses in a pilot unit. Reliability was calculated to be 0.92. The study surveyed a convenience sample of 1253 RNs before Compass implementation and 1319 RNs after Compass implementation. Nurse names were obtained from the hospital’s human resource database following institutional review board approval. Consent to participate was implied by voluntary participation, requested via organization e-mail. Participants were instructed to select the best answer as it pertained to all RNs in their unit, department, or area of nursing practice. For example, to measure autonomy, nurses were asked, ‘‘What percentage of RNs in my unit or area of practice consistently demonstrate autonomy by making decisions that are individual and patient centered within the context of a multidisciplinary approach?’’ To measure integration of the coaching and mentoring component of The Compass, the COMPAT asked, ‘‘What percentage of RNs in my area take a personal interest in actively coaching and mentoring new RNs to foster growth and development and achieve their full potential?’’ Participants selected from one of the following responses: less than 10%, approximately 25%, approximately 50%, approximately 75%, and greater than 90% (see Document, Supplemental Digital Content 3, http://links.lww.com/JONA/A376). Demographic data, including unit or area of practice; age, years as a nurse at the hospital, degree, certifica-
tion, position, and primary shift, were also collected in the COMPAT. Survey return rates were 45% in the before Compass implementation period and 30% after Compass implementation. Document, Supplemental Digital Content 4, provides a summary of the demographic characteristics of the subjects (http://links.lww.com/JONA/A378). The COMPAT fixed interval scale was converted to a numeric value: 1 (G10%), 2 (approximately 25%), 3 (approximately 50%), 4 (approximately 75%), or 5 (990%). The overall grand mean of the COMPAT at the hospital level was calculated at 3.34 in the preCompass implementation period and increased to 3.74 in the post-Compass implementation period. PPM integration into professional nursing practice was measured by calculating mean and z scores by both PPM component-specific question and department. Department and question results were divided into 1 of 3 categories; high, medium, or low. The categories were defined as 2 SEs above the mean (high), T2 SEs from the mean (medium), and 2 SEs below the mean (low). Each component-specific question and department were placed into a category based on the result. The highest mean score was standards of practice (4.40 pre- and 4.61 post-Compass implementation), and the lowest mean score was research (1.83 pre- and 2.02 post-Compass implementation) on a 1- to 5-point scale. Table 2 provides a summary of componentspecific question results, including enculturation level, mean, and z scores. The department pre-Compass
Table 2. Enculturation Level, Mean, and z Score by Component Pre-Compass Implementation
Coordination of care/case management Provision of patient care Standards of professional performance Standards of practice Evidence-based practice Research Innovation Nursing-sensitive indicators Professional growth Autonomy Performance improvement Shared governance Transformational leadership Relationship-based care Healthy work environment Culture of safety Coaching and mentoring Collaboration Recognition Community outreach
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Post-Compass Implementation
Mean
z Score
Enculturation Level
Mean
z score
Enculturation level
4.20 2.42 3.81 4.40 2.54 1.83 2.52 3.23 3.80 4.18 3.17 2.88 2.81 4.13 3.84 3.98 3.49 4.16 3.52 1.92
18.06 j19.30 9.78 22.26 j16.97 j31.79 j17.29 j2.31 9.59 17.57 j3.57 j9.72 j11.11 16.52 10.51 13.56 3.20 17.13 3.73 j29.85
High Low High High Low Low Low Low High High Low Low Low High High High High High High Low
4.37 3.24 4.22 4.61 4.23 2.02 3.05 3.56 3.96 4.40 3.30 3.47 3.31 4.45 4.13 4.31 3.79 4.44 3.82 2.26
11.50 j6.63 10.07 22.70 10.37 j32.08 j10.76 j2.67 4.33 15.71 j6.44 j4.06 j6.58 16.58 7.66 12.38 0.91 17.03 1.44 j25.21
High Low High High High Low Low Low High High Low Low Low High High High Med High Med Low
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Table 3. Enculturation Level, Mean, z Score by Department Pre-Compass Implementation
Rehabilitation Home care/hospice Pediatrics/pediatric intensive care/pediatric progressive care/neonatal ICU Surgery Oncology Intensive care unit Telemetry Patient care support/float pool Cardiac care unit Cancer center: chemotherapy/infusion, radiation oncology Adult and/or adolescent mental health Medical care units/medical progressive care unit Post anesthesia care unit Center for surgical care Dialysis, acute and chronic Surgical care/surgical progressive care unit Bone and joint center Neurosciences/neuro progressive care unit Family birthing center Emergency trauma center
Post-Compass Implementation
n
Mean z Score Enculturation level
n
Mean z Score Enculturation level
10 12 34
3.26 3.91 3.57
NA 9 6.22
NA High High
11 8 20
3.79 3.82 3.88
0.31 NA 0.76
Medium NA Medium
23 38 29 40 28 14 13
3.59 3.55 3.48 3.43 3.43 3.42 3.40
5.61 5.53 3.47 2.31 2.11 1.28 0.92
High High High High High High Medium
14 15 28 15 20 5 8
3.69 4.14 3.73 3.58 3.41 3.93 3.70
0.05 1.65 0.24 j0.26 j0.88 NA NA
Medium High Medium Medium Medium NA NA
20 62
3.37 3.35
0.56 0.30
Medium Medium
10 38
3.77 3.69
NA 0.12
NA Medium
14 19 15 59 23 24 47 21
3.34 j0.08 3.28 j1.24 3.19 j2.71 3.26 j3.14 3.11 j5.11 3.03 j6.94 3.07 j8.74 2.74 j12.75
Medium Low Low Low Low Low Low Low
11 15 17 20 13 18 16 11
3.70 3.49 3.77 3.58 3.84 4.05 2.96 3.23
0.09 j0.45 0.3 j0.33 0.51 1.35 j1.98 j1.08
Medium Medium Medium Medium Medium High Low Low
Abbreviation: NA = not applicable, G11 survey respondents.
implementation highest mean score was home care/ hospice (3.91), and the highest post-Compass implementation mean score was from oncology (4.14). Table 3 displays a summary of department-specific results, again calculating enculturation level, mean, and z scores. Correlations between pre- and post-Compass component integration were calculated using t tests (Table 4). A P G 0.01 was considered significant. Each component revealed an increase in mean score. All components demonstrated a statistically significant difference pre- and post-Compass implementation, with the exception of coordination of care/case management and performance improvement. The evaluation method supported a process to measure the impact of integration of The Compass. Conclusion The process of development, implementation, and evaluation of The Compass contributed to our 3rd Magnet designation. Through CN involvement, use of the literature, expert opinion, and innovative, creative design and implementation, The Compass PPM has become extremely important in professional nursing practice at St Cloud Hospital. The PPM describes how nurses practice, collaborate, communicate, and develop professionally. It defines what is important to nurses and drives current and future nursing practice.Through
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Table 4. Correlations
Coordination of care/case management Provision of patient care Standards of professional performance Standards of practice Evidence based practice Research Innovation Nursing-sensitive indicators Professional growth Autonomy Performance improvement Shared governance Transformational leadership Relationship-based care Healthy work environment Culture of safety Coaching and mentoring Collaboration Recognition Community outreach
Mean
Independent 2-Sample t Test (Unequal Sample Sizes, Equal Variance)
Pre Post
P
4.20 4.37
0.04
2.42 3.24 3.81 4.22
G0.01 G0.01
4.40 2.54 1.83 2.52 3.23 3.80 4.18 3.17 2.88 2.81
4.61 4.23 2.02 3.05 3.56 3.96 4.40 3.30 3.47 3.31
G0.01 G0.01 G0.01 G0.01 G0.01 G0.01 G0.01 0.09 G0.01 G0.01
4.13 3.84 3.98 3.49 4.16 3.52 1.92
4.45 4.13 4.31 3.79 4.44 3.82 2.26
G0.01 G0.01 G0.01 G0.01 G0.01 G0.01 G0.01
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the PPM, optimal patient outcomes are achieved. Future evaluation measurement will guide nursing strategic plans and strengthen PPM integration. During the Magnet designation process, St Cloud Hospital received an exemplary professional practice (EP1 source of evidence) report. Magnet appraisers found The Compass ‘‘visible, palpable, and threaded throughout all aspects of the organization.’’ They noted unsolicited comments from CNs about how the model informs and influences nursing practice. The video, Lynn’s Journey, was identified as an exemplary example of bringing the conceptual framework to life in a way that all can be related to and understood for all nursing staff. The development, implementation, and evaluation of The Compass successfully enhanced professional nursing practice and positioned the orga-
nization for nursing’s future. As stated by the CNO, ‘‘Guided by our Compass, the nursing excellence journey continues.’’
Acknowledgments The authors thank the following contributors to the development of The Compass: St Cloud Hospital’s Nursing PPM. Through their love for nursing and commitment to professional practice, The Compass was created: Laurie Annett, BSN, RN; Chelsie Bakken, MBA, RN; Deb Eisenstadt, MSN, RN; Mary Leyk, MSN, RN; Tiffany Omann-Bidinger, BSN, RN; Diane Pelant, BSN, RN; Joanne Reinhart, RN; Joyce Salzer, RN; Mary Schimnich, RN; Marian Seliski, BSN, RN; Kirsten Skillings, MA, RN, CNS; and Kate VanBuskirk, BSN, RN.
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