A key component of exemplary professional practice is a well-developed and articulated Professional Practice Model (PPM).1 The PPM is a framework that supports registered nurse control over the delivery of nursing care and the practice environment as well as serving as a guide in furthering an understanding of the work of nurses.1-3 According to the Magnet Recognition Program(R), a PPM is defined as "The driving force of nursing care; a schematic description of a theory, phenomenon, or system that depicts how nurses practice, collaborate, communicate, and develop professionally to provide the highest quality care for those served by the organization (e.g., patients, families, community).1^(pp41-42) Professional practice models integrate the alignment of nursing practice with the mission, vision, and values that nursing has adapted.2,4

Background

The Professional Development Council (PDC), 1 of 5 newly formed shared governance councils at this academic medical center, is composed of clinical nurses, nurse managers (NMs), a nurse researcher, professional development specialists, and a director from nursing administration. As its 1st priority, the PDC identified the need to develop a PPM to articulate a collective understanding of the excellent nursing practice already in existence and include active input from professional nurses throughout the health system.

Engaging Professional Nurses in Salons

With the full support of nursing leaders across the organization, a series of 1-hour "Nursing Salons," modeled on the work of Marie Manthey, MNA, FAAN, FRCN, were held.5 These salons were designed to generate conversations and insights about professional nursing to guide development of the PPM. Nearly 100 salons were scheduled, allowing for attendance by all nurses from every ambulatory or acute care unit or department. The salons, scheduled over a 2-month period, were held on days, evenings and nights, weekdays and weekends. Although participation in the salons was voluntary, 500 nurses attended on paid time with funding for attendance included in each unit budget.

A convenient location in the hospital was identified, and although not as intimate a setting as Dr Manthey's original salons, efforts were made to facilitate close, small group conversations. Questions were devised to help facilitate discussions of professional nursing care, the organization's mission, philosophy, and values and the foundations guiding practice. Discussion questions centered on how nurses saw those concepts actualized in their professional nursing practice. The goal was to articulate the common vision of excellence in nursing practice as understood and practiced by nurses, organization-wide. The questions were vetted through pilot salons with randomly selected clinical nurses. The end result was the development of 3 open-ended questions in which nurses were asked to

Reflect on the things that made them most proud of the care they provided;

Discuss what they expected from professional nurses caring for them or a member of their family; and

Describe what they felt was the foundation for their practice as a professional nurse.

Direct care nurses from throughout the facility were recruited to serve as facilitators, transcribers, or coders. The nurses who volunteered attended a 4-hour workshop, which included experiential learning about facilitating, coding, and transcribing; an overview of the purpose of the salons; and a discussion as to how the PPM would be used to guide practice. Every session was digitally recorded with attendees' permission, and responses were transcribed on large easels for review by the facilitator and participants to ensure that the context and intent of the statement were understood and accurate. After each session, the facilitator, transcriber, and coder reviewed the statements for interrater reliability.

Each nurse in the organization was sent a personal invitation from the PDC, flyers were distributed to advertise the salons and encourage attendance, and an announcement was displayed on the organization's intranet. To encourage open dialogue, separate salons were held for clinical nurses and NMs, with clinical nurses facilitating the salons for their peers and NMs facilitating the salons for NMs.

With a goal of encouraging active participation, each salon was composed of small groups of 20 or fewer. Before beginning each salon, the following guidelines were presented and agreed upon:

There are no right or wrong answers.

Give voice to your thoughts.

What is shared in the room stays in the room.

Listen respectfully and allow others to finish their thoughts without interruption.

Identifying Common Themes

Responses to the questions provided the PDC with a large volume of data on which to identify themes and define concepts. Over a 3-month period, council members reviewed all transcribed recording as well as the written responses for accuracy and completeness and to identify trends. Content was color-coded based on identification of common themes or concepts. Numerous round-table discussions and spirited debate resulted in agreement on 13 broad themes and 19 underlying concepts. Once these themes and underlying concepts were identified and defined they were sent to each unit-based practice council (UBPC) for review and agreement. This step gave members of the UBPCs an opportunity to validate the themes and provide further input throughout the process. Once the responses had been coded and commonalities identified, a PDC retreat was held with a goal of working toward consensus as to the final components of the PPM. The retreat was facilitated by the nurse researcher on the PDC. The PDC then met with a graphic artist to finalize design of the model. The graphic artist assisted in organizing the themes into a model that captured the interrelationships between the themes and the overall focus on excellence in patient outcomes through excellence in nursing practice.

The Professional Practice Model

Although describing the entire PPM is beyond the scope of this article, selected examples of concepts and the nursing quotes used to identify them are described to provide a sense of the final product.

Relationship-based care, defined as a therapeutic relationship between the nurse and the patient/family and essential to providing exceptional and compassionate care, was exemplified by the following comment6:

[horizontal ellipsis]for me, the patient comes 1st. Put that before everything else, my question is always, what's best for the patient. That has made everything so much simpler, having that perspective "what's best for that patient."

Respect and core values were identified as key to supporting nursing practice. Throughout each of the salons, nurses consistently described a desire to treat others the way they would want to be treated.

We can audit, have champions, check boxes, none of that matters. It's about who you are, your core values. Is this the right thing to do, not just book right, but right-right? Don't just check the box.

Having a good moral compass, your reputation as a good nurse and maintaining that reputation.

Accountability to the patient, family, and members of the healthcare team and the authority to develop and implement an individualized plan of care for the patient characterize the concepts of caring practices and collaboration.

Having the nurse go the extra mile, not just doing the basics. It's more than having a competent nurse but also someone who cares for the whole person, physical, spiritual, emotional. Our nurses are good at that.

Having knowledgeable nurses, knowing we have the support and resources we need.

Teaching parents how to care for their sick child. Really empowering the parents, knowing when they leave they are prepared.

Although the final component of the model was the achievement of optimal patient outcomes, this was actually identified first. Everything else was based on achieving optimal patient outcomes and to always provide individualized, holistic patient and family-centered care.

I always take into consideration, what will lead to the best outcome for the patient. I can't promise them they will go home and be the same. But I can promise to give them the best I've got.

Recognizing the story behind the patient, listening, validating who they are and what they want.

Implementing the Model

As a result of their engagement in creating the PPM, release of the model was anticipated by nurses from throughout the facility. Over a 2-month span, the PDC members took the model on the road with presentations to over 30 individual UBPCs and each of the 5 system-wide councils. After the initial roll-out, the Center for Professional Practice of Nursing (CPPN), in conjunction with the PDC, completed a needs assessment to discover where staff felt they needed more education and reviewed the curriculum to ensure that education covering each aspect of the model was available. The CPPN has since woven the model through their curriculum offerings and changed the general nursing orientation to include a discussion of the model.

Conclusion

Engaging nurses through the use of nursing salons was an overwhelmingly positive experience. Afterward, many nurses expressed a renewed sense of engagement, a positive impression of having been heard, and the joy of having a venue to discuss positive elements of their professional practice. The data obtained through these discussions provided the PDC with a rich tapestry on which to base the PPM. Because the model was designed and built using the stories of practicing nurses, it was seen as a representation of real-world practice. Nurses identify with the PPM because it depicts their view of professional nursing as described by them.

Acknowledgments

The authors acknowledge the contributions of the PDC; Carol Robinson, RN, MPA, FAAN; Toby Marsh, RN, MS, chief patient care services officer; and Ellen Kissinger, RN, MS, for inspiring and supporting this work.

References