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Developing a Nursing Practice Framework to Align With Strategy

Joan Gygax Spicer, PhD, RN, CCM, NEA-BC Patricia S.A. Sparacino, PhD, RN, FAAN Noris E. Larkin, BSN, RN

Clinical and administrative nurse leaders in a safety-net health system in Northern California developed and implemented a nursing prac- tice framework to complement the system_s 5-year strategic initiative (2015-2020). Their contributions have been integral to the health system_s strategic direction and success. This article summarizes highlights of the journey from intel- lectual curiosity to pragmatic im- plementation system-wide.

Intellectual curiosity is the seed of every successful journey. The jour- ney here summarized began in 2014 when clinical and adminis-

trative nurses, in a 100-bed hospital with associated community clinics, met to discuss the development of a nursing practice framework (NPF). The San Mateo Medical Center (SMMC), which is the safety-net health system for San Mateo County, California, comprises a public hos- pital with medical and psychiatric emergency services, 10 community clinics across a 744-square-mile county, and a skilled nursing facil- ity. Almost 75% of the patients who receive care at SMMC are low- income residents who are covered by Medi-Cal (California_s Medicaid program) or by San Mateo County_s Access to Care for Everyone pro- gram. Many of the patients have weak social support and have experienced the negative impact of physical, social, or emotional trauma on their health. Sixty-five percent of the patients identify a preferred language other than English; most of these patients iden- tify Spanish as their preferred lan- guage. The small cadre of RNs deliver nursing care at 18 points within the medical center, clinic system, and skilled nursing facility.

In many respects, the journey itself was more important than the

publication of Being and Becom- ing a Nurse at San Mateo Medical Center: A Nursing Practice Frame- work. Notable highlights include the importance of developing an inclusionary framework, aligning visually the NPF with the orga- nization_s strategic initiatives, ar- ticulating nurses_ contributions to financial stewardship, creating synergy of nurses_ work across the SMMC care continuum, validating externally SMMC nurses_ work, and developing a nursing brand.

The Journey

Developing an Inclusionary Framework

Rather than adopting a nursing theoryYbased professional prac- tice model, the organization_s clin- ical and administrative nurse leaders created an NPF to guide the devel- opment of nursing_s strategic goals and plans.1 They wanted this NPF to be culturally aligned, flexible, and adaptable2; meaningful to non- nursing colleagues; pragmatic; and inclusionary. Although the NPF complements the SMMC_s strategic initiatives and integrates the organization_s core values, its

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Author Affiliations: Chief Nursing Officer/Deputy Director (Dr Spicer), Nurse Practice Advisor (Dr Sparacino), and Assistant Chief Nursing Officer, Am- bulatory Nursing (Ms Larkin), San Mateo Medical Center and Ambulatory Clinics, California.

The authors declare no conflicts of interest. Correspondence: Dr Spicer, San Mateo

Medical Center, 222 W 39th Ave, San Mateo, CA 94403 (jspicer@smcgov.org).

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 website (www.jonajournal.com).

DOI: 10.1097/NNA.0000000000000663

http://links.lww.com/JONA/A641

goals and processes are nursing specific. Conveniently, there was no need to develop translational language to bridge nursing theory terminology with the organiza- tion_s terminology because the structure is shared. This was an important decision because, as the NPF evolved, nonnursing colleagues in the organization have supported nursing_s goals, processes, and outcomes.

Visually Aligning the NPF With SMMC_s Strategic Initiatives

Prominently displayed now in the SMMC_s administrative suite is a Bvisibility wall,[ which is labeled Advancing Nursing Practice. A vis- ibility wall is an element of Lean methodology that the SMMC adopted as a Learn-Engage-Aspire- Perfect methodology. Lean is a set of quality improvement tools, adapted from the Toyota Motor Company, to improve quality and efficiency and used by many health- care institutions.3 The wall visually aligns the work of SMMC nurses with each of the 5 True North Metrics that drive the organization_s strategic work: (1) patient centered care, (2) staff engagement, (3) excel- lent care, (4) financial stewardship, and (5) right care, place, time (Sup- plemental Digital Content 1, http:// links.lww.com/JONA/A641). These True North Metrics guide the orga- nization from the present to a future, preferred state of organizational health.

Articulating Nurses_ Contributions to Financial Stewardship

The organization_s nurses are com- mitted to demonstrating and quan- tifying their contributions to financial stewardship, especially in an environment where resources are rationed. The NPF emphasizes

the importance of value-added nursing in relation to the dose of nursing. Improving patient out- comes is strongly linked to the dose of nursing, which includes nurses_ education, certification, experi- ence, and skill set.4 (Supplemental Digital Content 2, http://links. lww.com/JONA/A642). In the 1st 3 years of the SMMC journey, sev- eral nurse-sensitive indicators have continuously improved including the reduction of falls with injury on the medical-surgical unit and reduction of restraints and seclusion on the acute psychiatric unit. At the baseline year, the rate of patient injury falls was 1.21/1000 patient- days, and at year 3, the rate was 0.15/1000 patient-days.5 The focus on recovery in the acute psychiatric unit includes an admission huddle with the psychiatric emergency ser- vice and the development of a safety plan before admission. At baseline, the rate of restraints and seclusion was 1.97/1000 patient-hours. Incre- mental improvement shows current trending at 1.14/1000 patient-hours of restraints and seclusion.6

Creating Synergy of Nurses_ Work Across the Continuum

Collaboration among nurses across the SMMC continuum of care has created an effect greater than the sum of individual efforts. Because clinical and administrative nurses recognize that nurse-driven endeavors have improved organizational pro- cesses and patient outcomes, they have amended the California Nurses Association Memorandum of Un- derstanding to include peer review for progression on the clinical lad- der. They were sensitive to avoid the pitfalls common to clinical ladder programs such as perceived sub- jectivity of managers, little added value to practice and patient care,

and high barriers to participation.7-9

Promotion on the clinical ladder and maintaining the appointment is now based on nurses developing and implementing a project that demonstrates their work with an- other part of the care continuum or their work directly impacting SMMC_s federal or state publicly reported metrics. A peer group is assigned to each nurse in the clinical ladder program; the groups approve, monitor, and evaluate the projects (Supplemental Digital Content 3, http://links.lww.com/JONA/A643).

Validating SMMC Nurses_ Work

The clinical practice, education, and leadership councils, roughly 60 members in all, took 3 years to collectively and collaboratively write, edit, and vet the NPF. The process impressed upon the nurses that they have a responsibility to share their knowledge and best prac- tices in caring for the ethnically diverse patient populations in this safety-net hospital. The process and outcome of this journey have increased their confidence in shar- ing their work. For the 1st time in SMMC_s history, in the most recent 12 months, they have presented 2 podium and 4 poster presentations at national and state professional meetings.

Developing an SMMC Nursing Brand

Distinctive infographics including a teal-green color scheme was de- veloped for the publication of the NPF. These now brand all com- munications related to SMMC nurses and nursing practice. Teal green was selected because it pro- motes peace, balance, and harmony while encouraging restoration and giving assurance. These communi- cation tools are used internally,

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including the SMMC_s governing board, but also externally.

Conclusion The NPF_s success has been re- markable, although its beginnings were modest with no guarantee of fulfillment. Despite the SMMC_s relatively small cadre of nurses and its fiscal constraints, the nurses_ commitment to their professional goals and their collaboration to further those goals has been essen- tial to the NPF_s success. The NPF has united the efforts of nurses in the medical center and clinics and provided a vibrant structure within which they can communicate, coor- dinate, and measure the nursing care that is provided to SMMC patients. Despite the NPF_s success thus far, its journey continues. Not- withstanding significant changes, improvements, and successful out- comes, processes continue to evolve, identifying and guiding the nurses_

work in the redesign of healthcare delivery across the organization_s care continuum, ensuring quality pa- tient care and collaborative care, and furthering the organization_s strate- gic direction and success.

Expanding nursing_s horizons can never wait on more budget, per- sonnel, or time! Journeys such as ours depend on shared vision and courageVand no guarantee of suc- cess. Nursing can advance with bold leaps of faith. Our team stepped away from the daily routine, bridged perceived boundaries, and explored new ideas and perspectives.

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https://www.ucdmc.ucdavis.edu/nurse/practicemodel

http://www.eventscribe.com/2017/posters/APNA/ListView.asp