Respect for nursing as a profession has made great strides in the last several decades, with more progress to be made in the future. Professional practice models allow nurses to take charge of their careers in ways that enhance work-related self esteem, career satisfaction, and most importantly, patient outcomes. Given the shortage of nurses, lingering detrimental portrayals of nurses in the media, and the unrelenting pressure to do more at less cost, nursing leadership will well serve the medical community by strongly advocating for the professional practice of nursing.
The American Association of Colleges of Nursing (AACN, 2015) recommends several professional practice models of nursing. These include magnet hospital recognition, programs that provide preceptorships and residencies for nurses, differentiated nursing practice, and interdisciplinary collaboration. Each provides unique emphases for nursing leadership to create work environments that allow nurses to reach their full career potential.
The first Magnet Hospital study of 40 hospitals was published in 1983 (AACN, 2015). Selected hospitals throughout the United States were known for successfully recruiting and retaining nurses, with better patient outcomes. These hospitals were studied throughout the 1980s and into the 1990s to discover what qualities they possessed. Then beginning in 1993, the American Nurses Credentialing Center (ANCC, 2015) created the Magnet Nursing Services Recognition Program, awarded to the best hospitals and longterm care facilities. Magnet organizations are expected to demonstrate transformational leadership; structural empowerment; exemplary professional practice; new knowledge, innovations and improvements; and empirical outcomes. Further study has verified that magnet hospitals have improved patient outcomes.
Preceptorships and residency programs provide ways for nurses to begin their professional practice with maximum knowledge and experience (AACN, 2015). Students and/or recent graduates are partnered with and/or mentored by staff nurses for additional clinical and educational experience. In such an environment, nurses become more comfortable in their clinical professional roles, increasing knowledge, skills, and confidence. These programs are being developed in response to the demands on new nurses (Welding, 2011). The transition from student to professional has been difficult and stressful, leading to high levels of turnover in the first year after graduation Hospitals that offer these programs improve recruitment, commitment and retention, as new nurses feel more supported in their roles, with justifiable confidence in their knowledge and abilities The additional training has led to improved patient outcomes.
Differentiated nursing practice models define different levels of clinical nursing by educational attainment, clinical skills, job descriptions, decision-making, and pay scales. This allows a variety of healthcare settings to best take advantage of their nurses’ varied education and experience Many differentiated models have clearly defined steps for advancements, a “clinical ladder” that nurses can climb with experience, additional education, specialty certification, or other defined factors. This has led to increased job satisfaction and retention, and improved patient outcomes.
Interdisciplinary collaboration models provide joint decision-making and communication among healthcare providers as a team, each individual with their own areas of specialization. Collaborators may include nurses, doctors, dietitians, physical therapists, social workers, and others. This model is particularly useful in the treatment of patients with multiple or complex problems. Studies have shown that this model also leads to job satisfaction and improved patient outcomes.
These models may be combined to optimize nursing care and to attract qualified individuals to the nursing profession. Nursing leadership must create environments in hospital and other healthcare settings that support nurses in these professional practice models. The goal is to make optimal use of the knowledge and skills of professional nurses, thus creating optimal patient outcomes.
For the magnet model, the expectations for leaders is that they will have excellent nursing services management, philosophy and practices; adhere to standards for improving quality of patient care; lead as chief nurse executive and have competent nursing staff; and respect diversity (AACN, 2015). Leaders must be prepared to advocate in support of staff and patients, and must be in an executive position where they can strategically influence the organization’s boards, directors and trustees (ANCC, 2015). The goal is improved patient outcomes through nurse empowerment and through adoption of best practices based on the evidence. Structures must be in place to provide executive decision-making, shared governance, multidirectional communication, and partnerships in the community. Mechanisms must be utilized to provide continuous quality improvement and innovation, with monitoring of outcomes and measurable results.
Preceptorships and residencies require leaders to provide partners and mentors; enforcement of contracts that detail educational opportunities offered in exchange for clinical duties; and re-imagining of orientation activities to enhance previous education and experience, eliminating duplication of effort. In addition, time and recognition for experienced nurses who assist the less experienced, as well as structure and materials for things such as classroom and online education, need to be provided.
Where there is a differentiated nursing practice model, leaders need to clearly define roles and steps; opportunities for educational advancement need to be provided, with planning to provide time, money, space, and energy for nurses to participate in educational activities. Pay scales and job descriptions should reflect the difficulty of specialization and decision-making opportunities in each step on the ladder.
Interdisciplinary collaboration models require leaders to provide time and space and technology to improve collaboration and coordination of efforts among team members and perhaps even between teams, to help establish best practices. From each professional according to his or her unique abilities, to each patient according to his or her needs. Communication and respect for each others’ abilities, along with conflict resolution, are required for an optimal interdisciplinary collaboration environment. As with any modern environment, technology can and should be used to facilitate communication.
These models have many commonalities. Nurses should look for practices that allow them meaningful input to enhance patient safety and outcomes. Nursing staff levels need to be adequate. The organization should include nursing leaders on governing committees that decide policy and operations There should be a formal program of improvement and advancement. Nurses should have a variety of roles within the organization, based on education, certification, specialization, advancement and credentialing, including as nurse scientists, mentors, and educators. These roles should be recognized in titles and compensation. While nurses should have power over their own roles and patient outcomes, with appropriate levels of decision-making, there should be a recognized role in the organization for a strong nurse executive. This nursing leader should be part of the governing body, report to the highest level operations or corporate officer, have authority and accountability for all nursing care and financial resources, and be supported by adequate personnel including her own staff.
Stanford Health Care (2015) implemented a professional practice model in January of 2010. At that time, they invited 60 nurses from across their organization to define the model. These nurses collaborated with Dr. Maria O’Rourke, a recognized expert in professional practice models, to develop a role-based practice program that incorporated evidence-based best practices in nursing. The role-based program educates nurses in all their roles: As practitioner (for each nursing task, there is responsibility and accountability), as leader (with decision-making and coordination of care), as scientist (assuring evidence-based practice and utilizing institutional protocols), and as transferor of knowledge (communication regarding the plan of care to patients, health care providers, and loved ones). This program makes nurses better at their jobs and more confident, and improved patient outcomes. Leadership is shared and nursing staff have a voice in their own professional roles, as well as accountability for outcomes. There are elements of differentiated roles and interdisciplinary collaboration. There is a structure in place consisting of a coordinating council, seven organization-wide councils, sub-councils and committees, and one or more councils in each department and unit responsible for patient safety, quality service, decision sharing, innovation, problem solving, and other collaborations. The 2010-2015 strategic plan was developed by nursing leaders and nursing staff, including over 200 council members and staff from over 25 clinical areas. There are annual updates at the beginning of each fiscal year. Each inpatient unit has daily meetings and a “visibility wall”: An area dedicated to transparent information and continuous improvement.
Welding (2011) provides an example of the implementation of a nursing residency program at a western Pennsylvania medical center. The residency team consisted of nursing administrators and educators. They chose nurse managers, and the managers chose graduate nurses. Each graduate nurse attended orientation during the summer of 2008, then a year-long clinical orientation with a preceptor. Each nurse manager, preceptor and resident attended six 1-day intensive leadership development activities over nine months, to learn about management, communication, leadership and learning styles Residents also attended monthly sessions. All participants attended the last session in April of 2009. Evaluation was ongoing at the time of publication, but preliminary results suggest that the residency program will provide improved critical thinking skills and safer clinical practice.
Given the demands of the current health care environment, with increases in patient loads and the desire for best practices in care at the lowest possible price, many health care systems are striving for improvements in patient outcomes through the use of one of more professional practice models. Nursing leadership can support the development of professional nursing practices in their health care organizations by seeking executive collaboration to support the needed structures and programs. They must insist upon time, space, and finances to educate staff and provide for professional advancement, while developing systems of best practices to optimize patient outcomes. Efficient and effective nursing based upon the evidence is the professional nursing of the future.
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