Recent reimbursement changes have resulted in a focus on providing cost-effective, quality care in episodes, not visits. Administrators face lower nurse satisfaction, an increased turnover rate, and a nursing shortage. In the 1970s, when acute care experienced the same challenges, nursing investigated organizational conditions to develop effective practice models (Maas, 1973). Prior to this time, acute care practice models were described as a method of care delivery (i.e., team nursing).
In 1983 the American Academy of Nurses funded a study of hospitals successful in recruiting and retaining nurses (i.e., served as magnets for nurses). In these magnet hospitals, researchers found a participative management style, decentralization, knowledgeable and committed leaders at all levels, adequate qualified staff, competitive salaries and benefits, opportunities for promotion, an educational environment, and a positive perception of the image of nursing. Staff nurses experienced control over practice and practice-setting decisions as well as nurse-physician collaboration.
A new generation of professional practice models creating a practice environment based on professional nursing values of accountability, commitment, collaboration, continuity, authority, and autonomy followed (Joy & Malay, 1992). As a result, nurses practicing in these models have gained greater responsibility and authority for managing patient care and unit governance. Moreover, these nurses are more accountable and responsible for the design, delivery, and evaluation of nursing services.
Despite practice differences between hospital and home care, there is evidence to support shared values of organizational attributes. Flynn & Deatrick (2003) found that home care nurses valued some of the same attributes as nurses in the magnet hospital study. Though research is limited, there are warning signs that the home care practice environment does not reflect these attributes.
Smith-Stoner (2004) found that 50% of respondents indicated administrators used inadequate communication skills with staff. Ellenbecker (2001) reported nurses less satisfied with their relationship to administration and with their ability to affect agency.
Today, home care practice models have the narrow purpose of providing care as opposed to the broader focus of a genuine professional practice model in acute care. For example, many home care administrators describe their model as a primary care or a team approach model (Humphrey, 2002).
Consider a New Home Care Professional Practice Model
Imagine a home care organization that incorporates attributes consistent with nursing values. A professional practice model that values nurses' control over practice setting decisions could bring staff nurses together to identify barriers that inhibit nurses' participation in decision making. Consider what might occur if policies related to productivity standards were eliminated instead of simply counting visits made per day or week (Humphrey, 2002). When an RN is evaluated only on these terms, might that send a message that time spent on OBQI activities is not valued?
The collective wisdom of administration, nurses, and researchers is needed to develop professional practice that will reflect nursing values while providing cost-effective, quality care. Let's begin the journey!!
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