Leadership In Nursing

The Evolution of a Nursing Professional Practice Model

Through Leadership Support of Clinical Nurse Engagement, Empowerment, and Shared

Decision Making

Anursing professionalpractice model (PPM) is the guiding theoreti-

cal and conceptual model

that frames the foundation

for nursing professional

practice.1,2 Utilization of a

professional practice model

guides nursing practice and

fosters professional identity,

encouraging alignment to the

organization’s mission and

vision, job satisfaction,

improved quality of patient and

family outcomes, and enhanced

interprofessional communication.2 When a model guides professional nursing practice, nurses can articulate

the impact of nursing care on improving patient and family outcomes. With leadership endorsement and sup-

port, the PPM’s theoretical framework becomes the lens through which nurses see themselves; therefore, a

decisive imperative factor in selecting the underpinning theory for an organization’s PPM is core in its appli-

cability to the staff’s practice.

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Jennifer Cordo, MSN, ARNP, NE-BC, and Deborah Hill-Rodriguez, MSN, MBA, ARNP, NE-BC

Afree-standing pediatric hospital on its Magnet ® journey

striving for its third designation identified an opportunity to engage staff in the evolution of the organization’s practice model. Application of the shared leadership structure for joint decision-making empowered staff to “own” the PPM’s devel-

opment and implementation. Nurse leaders within the organization first embraced the concept of clinical nurses engaging their peers across the organization in identifying Comfort Theory’s compatibility with the organization’s val- ues and mission. Comfort Theory was selected as the theory

most applicable to the staff ’s practice by a voting process by nurses across the organization. Comfort Theory’s universality and application to both nurses, staff, and patients/families was easily understood and simple enough to guide practice. Comfort Theory’s inherent emphasis on physical, psychospiri- tual, sociocultural, and environmental aspects of comfort contributed to a proactive multifaceted approach to care to guide nursing practice.3 The easily applied framework of Comfort Theory within pediatric practice is strengthening and satisfying for pediatric patients, families, and nurses, and benefit organizations that value a culture of comfort.3

Comfort is a positive outcome that has been linked empiri- cally to positive institutional outcomes such as increased patient satisfaction and cost–benefit ratios.3

PRACTICE MODEL EVOLUTION Exemplary professional nursing practice must be designed, implemented, and advanced over time.4 As the nursing profes- sion continues to advance its unique discipline and practice, it

is vital that nursing practice and research are guided by theory derived from nursing knowledge.2 As a Magnet-designated organization striving to obtain its third designation, an oppor- tunity was recognized to enhance the current practice model to a true professional practice model based on a theoretical framework. A professional practice model defines the relation- ship between an organization and the nurses, and is unique to each organizational culture. The first step in the model evolu- tion was to identify the core elements required within a pro- fessional practice model. The ANCC Magnet Recognition Program® book Magnet: The Next Generation: Nurses Making the Difference was used as the foundation for the PPM develop- ment.4 Drenkard et al.4 identified basic elements of exemplary professional nursing practice to be included in the develop- ment of a PPM. The PPM needed to include at minimum nursing’s values, leadership, collaboration, professional develop- ment, and a care delivery system. Other elements may be included, but these key attributes must be addressed and included in the design and implementation.

UTILIZING THE SHARED LEADERSHIP STRUCTURE TO ENGAGE AND EMPOWER STAFF The Magnet Program director presented the concept of a PPM to the shared leadership council to educate the clinical nurses on the purpose and benefits of a professional practice model grounded by a theoretical framework. The nurses were shown sample PPMs from other organizations to stimulate thought on model development for this organization. The council was empowered to drive the PPM development and theoretical framework.

Development of the PPM Schematic Through shared decision making, the nurses thought through various model shapes including a palm tree, starfish, and heart, and then collaboratively decided on a star-shaped model with a diamond in the center. These nurses were guided by the notion that nurses should reach for the stars in nursing excel- lence and are the “nursing stars” of the interprofessional health care team. They decided to place the patients, families, and global community in a diamond at the center of the model because they were viewed as precious “gems.” The PPM schematic is referenced in Figure 1.

Once the shape was decided, the council began work on developing the key elements of the 5-point star. The council members decided on the 5 core elements of the PPM to be collaborative relationships, nursing professionalism and values, recognition and rewards, leadership, and patient care delivery and outcomes. Upon establishing the 5 key elements, the council members identified subcategories within the key elements as the structures and processes across the organization supporting these elements. The PPM subcategories are referenced in Table 1.

Selecting a Theoretical Framework The council members identified 3 nursing theories they felt would align well with the organizational culture, mission, vision, and values. The nurses chose Katharine Kolcaba’s Comfort Theory, Jean Watson’s Caring Theory, and Madeleine

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Figure 1. Evolution From a Professional Model of Care to a Professional Practice Model

Leininger’s Transcultural Nursing Theory. The nurses collabora- tively developed a presentation to educate staff across the organization about all 3 nursing theories. The nurses hosted a house-wide educational event to unveil the new PPM and engaged the audience in the selection of the PPM’s theoretical framework. The nurses actively engaged the audience in an entertaining simulated scenario acted out by various council members. After the descriptive information on each theory was presented via a slide show, the nurses performed skits on how to bring the theory alive and what it could look like to not practice according to the theory. These skits highly engaged the audience and helped them to see each theory application in practice. At the end of the presentation, the audience utilized technology to vote in real time for the theory they felt was best suited for the organization. Kolcaba’s Comfort Theory was chosen as the theoretical framework for the new professional practice model based on this important feedback.

The Comfort Theory is an example of a multifaceted PPM with a holistic approach that aligns with the values and mission of nursing within the organization. The primary focus in pediatrics is individualized care, collaborative goal setting, holistic care, and prevention of disease.3 Kolcaba defines comfort as “the immediate state of being strengthened through having human needs for relief, ease, and transcen- dence” through the 4 contexts. When “comfort” is achieved, the child and family are able to participate in the activities needed to achieve health through therapeutic relationships.3,5

ADOPTION AND ENCULTURATION OF THE PROFESSIONAL PRACTICE MODEL Adaption of the new PPM among the nursing staff, with Comfort Theory as its conceptual framework, began by council members teaching their nursing peers the core concepts of the PPM and its foundational Comfort Theory framework. Education was provided on all shifts, including weekends. The education was provided in a room set up in a comfortable environment including chair massagers, hand creams, refreshments, light music, and aromatherapy to enhance the environment and increase a sense of comfort for the staff.

The interactive online version of the PPM was developed and presented to staff nurses at staff meetings. To further engage the staff with Comfort Theory, staff were provided an opportunity to meet the nursing theorist, Dr. Katharine Kolcaba, who developed Comfort Theory. She was invited to visit the organization to provide insight and feedback as to the organization’s adoption of Comfort Theory. In order to prepare for her arrival, a Comfort Theory task force was formed as a partnership between the council members and nursing leadership team members for sharing decision-mak- ing processes in preparation for Kolcaba’s visit. This comfort task force collaborated to coordinate various activities for Dr. Kolcaba’s visit including:

• A Kolcaba meet and greet breakfast event offering vari- ous comfort measures

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Figure 2. Comfort Theory Presentation by Dr. Kolcaba

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Table 1. PPM Key Components and Subcategories

Patient, families, and global community Nursing’s mission, vision, and philosophy

Collaborative relationships • Values and guiding behaviors • Academic partnerships • Clinical and nonclinical departments that collaborate with nursing

Nursing professionalism and values • Professional development • Evidence-based practice and nursing research • ANA Code of Ethics • State nurse practice act • ANA Scope and Standards of Practice • Peer review

Recognition and rewards • List of several recognitions and rewards offered to nurses • Professional ladder • Compensation rewards • Buddy program

Leadership • Nursing shared leadership councils • CNO advocacy • Community and organizational leadership • Preceptorship/mentoring • Succession planning

Patient care delivery and outcomes • Nurse residency program • Transitional program • Family-centered care • The Comfort Theory Model • EBP/outcome-driven practice • Ethics and compliance • Magnet Recognition Program® standards • Patient safety programs • Organizational culture training

CNO, chief nursing officer; EBP, evidence-based practice.

• Comfort Theory presentation for 1 continuing educa- tion unit (Figure 2)

• Unit rounding • Interprofessional train the trainer session highlighting

methods to implement the Comfort Theory • Nursing Shared Leadership Council meetings to engage

staff in building awareness of potential nursing evidence- based practice& research using Comfort Theory as the theoretical framework.

The train-the-trainer session involved and engaged interpro- fessional team members on ways to incorporate Comfort Theory into everyday practice. This session was an interactive open discussion that brought forward several suggestions in implementing the Comfort Theory within the organization. The team members recognized the natural application to processes already in place and the potential naming modifications for “comfort” within existing processes and the potential for several new ideas. This session generated excitement among the staff on creative ways to incorporate the Comfort Theory into practice.

Application of the PPM and the Comfort Theory conceptu- al framework have been implemented in several ways, and staff

continuously come up with innovative ways to apply comfort measures throughout the organization. Comfort Theory is embedded throughout the PPM; therefore, the framework for nursing practice is continuously supporting an environment and culture based on comfort. The nursing mission statement, based on the organization’s mission to “provide compassion and com- fort through innovative advanced care for our children and families” and vision “we will be where the children are, provid- ing comfort through exceptional nursing care” demonstrate the nursing department’s commitment to Comfort Theory as the conceptual framework for the PPM.

The Patient Care Delivery and Outcomes section of the PPM is exhibited through the comfort calls and comfort rounds. Comfort calls were developed to enhance the patient care deliv- ery experience for parents/caregivers that are unable to be phys- ically present with the patient by keeping families updated with the patient’s plan of care. Families are called when there is a change in patient status, transfer to another unit, post-operatively for updates, and whenever a change in patient’s plan of care occurs. Comfort calls are performed at least once a shift in the intensive care units and documented in the patient’s medical

record. Another nursing initiative that demonstrates application of the PPM’s Patient Care Delivery and Outcomes section is hourly comfort rounds. Hourly rounds is a standardized way of nurses to anticipate their patient’s and family’s needs on an hourly basis. It was suggested by Dr. Kolcaba to change the terminology to include the word “comfort” because comfort was already part of the hourly rounding assessment.

CASE SCENARIO: BRINGING THE COMFORT THEORY ALIVE WITHIN AN INPATIENT SURGICAL UNIT The largest patient population admitted to the inpatient surgical unit (2 East) is children and adolescents that are admitted for spinal fusion surgery. The care for these patients is guided by the components of the Comfort Theory. The 4 contexts of physical, psychospiritual, sociocultural, and envi- ronmental are continually assessed, addressed, and evaluated.

Pre-Admission Prior to admission, the child’s fears of admission are addressed by attending a pre-surgical orientation, guided by a child life specialist in collaboration with the RN liaisons in the orthope- dic-spine office. The psychospiritual needs are addressed as they are exposed to the procedure that will be completed, addressing the potential pain needs (physical) the child will endure. The child is also able to touch, smell, and feel the physical environ- ment of the operating room and post-anesthesia care unit (PACU) while touching apparatuses that will be used during the case. At the conclusion, the child and family then meet with the RN liaison to receive a comprehensive education plan in partnership with the families, addressing all potential fears. At this time, a collaborative plan of care is created with the patient and family’s comfort concerns in mind.

Admission: Pre-Operative Upon arrival before surgery, the child is admitted to a private room with open visitation policies to allow for support from family and peers (sociocultural) to assist in relieving the anxiety of the surgery. During the admission process, a full admission history is completed focusing on the 4 contexts of comfort. Special attention is placed on the needs for pastoral care. The parents bring their plan of care from the pre-admission session and have an open conversation with the nursing staff and patient to ensure partnering in the care of their child. To further enhance individualized care, the nurse, in alignment with the child life specialist, assists the child in the completion of the “All About Me” poster that is placed at the bedside for all staff members to understand “who” the child is, including their likes and dislikes. This allows for a personal connection with the child, establishing parameters that will ensure “comfort” of the child, which is individualized and developmentally appropriate, during this potentially painful surgical procedure.

An individualized plan of care for “comfort” is created upon admission and is evaluated on a shift-to-shift basis throughout the duration of the child’s admission. The com- munication board at the bedside has areas for communication of current and future pain management and plan of care

updates, and has a section that allows for 2-way communica- tion between the staff, child, and parents, which all parties are encouraged to write on at any time. Throughout the admis- sion, proactive comfort rounds are completed every hour to ensure that pain needs, intravenous needs, toileting needs, and environmental needs such as ambulation are being met; at this time, interactive communication between the staff and patient/family is collaborative and patient focused. The night before surgery is about providing a soothing, calm atmos- phere for the child and family, allowing rest, in preparation for the surgical procedure in the morning.

Admission: Intra-Operative In the morning, when the child is taken to the operating room (OR) suite, the parents escort the child and remain with their child through induction, ensuring both parties’ psychospiritual calmness. Once the child is in the OR, the comfort strategies are geared toward the parent’s needs. The parents receive text update notifications to know what stages of the surgery are in progress. As well, the ortho spine RN liaison comes and speaks with the family every 1 to 2 hours to provide updates, answer questions, and provide reassurance to the concerned family. When the patient arrives in PACU, the 2 East staff escort the parents to the PACU, preparing them for the sights and sounds of the area. The parent is by their child’s side when they “wake up,” relieving both the parents’ and the child’s fears of the unknown. The parents are able to stay with the child and escort the staff back to the room when the time comes for transfer back to 2 East.

Admission: Post-Operative The main focus of comfort post-operatively is pain manage- ment. In addition to the comfort plan of care that was initiated and monitored since admission, a pain plan of care is collabora- tively established with the family and child. The first need addressed is therapeutic medication management through patient-controlled analgesia (PCA) pump modality. Traditionally, patients undergoing spinal fusion surgery are “log rolled” every 2 hours. This procedure can be painful because motions are not always fluid during the turning process, and the patient also becomes “stiff ” between moves. Our unit uses a specialty motion bed to avoid the traditional log roll. Every 20 minutes, the bed gradually transitions the patient from left to right and right to left. During this time the child life specialist provides distraction and guided imagery, and they teach the child “com- fort” positioning that is in alignment with the post-operative plan of care. During comfort rounds, the nurse assesses the child’s pain needs at minimum every hour, at which time they provide both verbal updates and utilize the communication board with the family and child. The communication board focuses on the current and target pain score, type of medica- tions the child is on including side effects, and after the PCA is discontinued, the last and next dose of medication times. In addition to the PCA, gabapentin is started immediately post- operatively to enhance the uptake of pain medication.

On the first post-operative day, as the first ambulation occurs, the child is encouraged to use the PCA prior to the ambulation

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process. While the physical therapist guides them through each movement, a music therapist enhances the process by walking alongside the patient, playing soothing songs on the guitar.

As the child transitions through to discharge (day 3 post- operatively), the PCA is changed to oral oxycodone/aceta- minophen. Comprehensive education is provided to the patient and family regarding the dosing, administration times, and side effects, especially nausea. Meals are centered around pain medication administration times to limit the potential of nausea and vomiting, for which an antiemetic is also available. In addition to nausea, as with any comprehensive surgery with increased bed rest, bowel management is vital to recov- ery. To prevent the discomfort related to abdominal disten- tion and constipation, an individualized bowel management protocol is set into action as part of the plan of care.

From post-operative day 2 until discharge, “bedside bud- dies” and pet therapy are provided for much needed diver- sional activities. This ensures age-appropriate activities and peer interactions during this time of “loss of control.”

Post-Discharge After the child returns home, the orthopedic spine nurse calls the family on a daily basis for several weeks, until the child resumes some baseline activity patterns, and the family is comfortable with the care. The home environment is assessed to ensure the child can freely move around, including the type of bed the child is sleeping in for back support. Pain management is reviewed with each call and adjustments are made as needed. NL

References 1. Schaffner LD, Tillett NL, Volz TM. Empowerment works! Clinical nurses and

the professional practice model. Nurs Manage. 2016;47(7):11-14. 2. Mullen JE, Asher LM. Implementation of a nursing professional practice

model of care in a pediatric hospital. Pediatr Nurs. 2007;33:499-504. 3. Kolcaba K, DiMarco MA. Comfort Theory and its application to pediatric

nursing. Pediatr Nurs. 2005;31:187-194. 4. Drenkard K, Wolf GA, Morgan SH. Magnet: The Next Generation: Nurses

Making the Difference. Silver Spring, MD: American Nurses Credentialing Center; 2011.

5. Marchuk A. End-of-life care in the neonatal intensive care unit: applying comfort theory. Int J Palliat Nurs. 2016;22:317-323.

Jennifer Cordo, MSN, ARNP, NE-BC, is nursing excellence man- ager & Magnet Program Director at Miami Children's Hospital- Nicklaus Children's Hospital, part of Miami Children's Health System, in Miami, Florida. She can be reached at [email protected]. Deborah Hill-Rodriguez, MSN, MBA, ARNP, NE-BC, is the Clinical Nurse Director at Nicklaus Children's Hospital.

Note: The author would like to acknowledge Jackie Gonzalez, DNP, MBA, ARNP, NEA-BC, FAAN, senior vice-president and chief nursing officer, for her leadership and vision in disseminating the success of our professional practice model enculturation. She personi- fies transformational leadership and continues to guide the nursing department to strive for excellence.

1541-4612/2017/ $ See front matter Copyright 2017 by Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.mnl.2017.07.009

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