Kelly S.

Miles
Roberta Vallish

Creating a Personalized
Professional Practice Framework
For Nursing
EXECUTIVE SUMMARY
Any organization on the journey to
nursing excellence might initiate its
search for a professional practice
framework by exploring the many
nursing-specific theories, frameworks, and conceptual models that
are readily available in the literature.
Although adopting an off the shelf
professional practice framework for
nursing may sound easier for a
nursing organization than creating
its own framework, achieving a
good fit into an existing culture is
more difficult when adopting rather
than creating a practice framework.
Even though creating a customized
framework requires a considerable
amount of upfront time, dedication,
and a willingness to make some
mistakes along the way, in the end
a customized framework ensures
cultural alignment.
This framework describes the foundational structures and guiding
principles, the key processes that
influence how work is conducted,
and the outcomes desired as the
result of the work.
Identifying evaluative methods for
determining progress on identified
strategic intents was crucial in
bridging the gap between theory
and outcomes.
This model continues to provide
flexibility and adaptability to meet
needs in a constantly changing
health care environment and difficult economic times.

SHANDS JACKSONVILLE
Medical Center (SJMC)
set out to identify a
framework to guide
nursing practice, the nursing leadership team conducted an extensive search of existing nursing
frameworks to find a model that
would compliment work already
in progress, support frontline staff,
and be easy for nurses at all levels
to understand. To our dismay, the
perfect framework to fit our culture and aspirations did not seem
to exist. Hence, we set forth creating our own practice framework.
In this article, we will share the
details of our comprehensive
framework and introduce the
resources and tools we found useful in constructing a personalized
approach to this complex endeavor.

HEN

A Review of Existing Nursing

Models
Any organization on the journey to nursing excellence might
initiate its search for a professional practice framework by exploring the many nursing-specific the-

KELLY S. MILES, MSN, RN, NEA-BC, is

Vice-President and Chief Nursing Officer,
Shands Jacksonville Medical Center,
Jacksonville, FL.

NURSING ECONOMIC$/May-June 2010/Vol. 28/No. 3

ories, frameworks, and conceptual

models that are readily available
in the literature. We found most
traditional nursing models are too
narrow in scope as they do not
take into account the new variables applicable to achieving a
broadened definition of effective
and efficient nursing care such as
cost, budget, length of stay, regulatory compliance, and patient and
employee satisfaction. In other
words, most nursing models were
not comprehensive enough to adequately support the new reality for
nurses practicing in todays complex environment.
SJMC believes these new variables are major factors influencing
our practice and organizational
outcomes. These nontraditional
variables have actually established equal footing with the historical virtues associated with providing quality nursing care.
Hence, SJMC continued its search
for a framework that would be
comprehensive enough to validate
the importance of these new variables while continuing to honor
traditional nursing values.

ROBERTA VALLISH, MSN, ARNP, is an

Advanced Registered Nurse Practitioner,
Research Coordinator, and Nursing
Institutional Review Board Member,
Shands Jacksonville Medical Center,
Jacksonville, FL.

171

Figure 1.
Shands Jacksonville Professional Practice Framework for Nursing

STRUCTURE

PROCESS

Regulatory and
Professional
Standards

MISSION

CLINICAL

ADMINISTRATION

VISION

VALUES

RESEARCH

EDUCATION

PHI
LOSOPHY

Performance
Improvement,
Evidence-Based
Practice and
Research

Participatory
Management
The Eight
Dimensions of
Patient-Centered
Care

OUTCOMES

SERVICE
Patient/Family Satisfaction
Community Service
Nursing Image

PEOPLE
Recruitment and Retention

QUALITY
Quality Outcomes
Culture of Patint-Centered
Care and Safety
Integrated Information
Management

FINANCE
Optimize Financial
Resources

GROWTH
BEST Intiative

Searching for an Alternative

Solution
After being unsuccessful in
finding a nursing model we could
readily adopt or adapt to meet our
needs and all of the variables
important to nursing, we continued to refine our search by asking
several questions. What do we
value and what are our guiding
principles? What strategic outcomes are important to nursing
and our organization? What structures and processes are necessary
to accomplish our desired outcomes? How will we evaluate the
effectiveness of our practice?
With these questions in mind,
we came upon Donabedians
Structure, Process, and Outcome
(SPO) Model (1980). We found
this model to be a great starting
place to assist in creating our personalized framework. Donabedians
three-dimensional model refers to

172

(a) structure as the relatively stable characteristics of the providers

of care, of the tools and resources
they have at their disposal, and of
the physical and organizational
settings in which they work (p.
81); (b) process as the necessary
technical skills, interpersonal
aspects of care, and critical treatment considerations; and (c) outcome as a change in status that can
be attributed to antecedent structures and processes. Moreover, we
found
support
for
using
Donabedians model as a guiding
framework for nursing practice
from Hoffart and Woods (1996)
who defined a professional practice model as a system (structure,
process, and values) that supports
registered nurse control over the
delivery of nursing care and the
environment in which care is
delivered (p. 354). Hoffart and
Woods (1996) support the incor-

External Validation of
Excellence
Efficient Throughput

poration of subsystems in a professional practice model including

(a) participatory management, (b)
a designated care delivery model,
and (c) staff rewards and recognition.

Personalizing a General Framework

Using the aforementioned
resources, SJMC set out to establish its own personalized, threedimensional framework that
describes key structures, processes, and outcomes and the relationships among the three dimensions. Our structure consists of the
guiding principles we established
to motivate and support nursing
practice. The process dimension
of our framework identifies the
internal and external influences
that affect how we conduct our
work. The outcomes dimension
identifies our desired results or
strategic intents (see Figure 1).

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STRUCTURAL DIMENSION
Guiding Principles
The outer rung of our structural dimension encompasses the
overarching and guiding principles for nursing at SJMC: our nursing mission, vision, values, and
philosophy. These guiding principles exemplify the goals and aspirations for nursing and guide the
purpose of our day-to-day work.
The chief nursing officer (CNO)
personally introduces all new
nursing employees to the guiding
principles during orientation. In
addition, the guiding principles
were communicated via (a)
numerous forums, (b) multiple
town hall sessions, (c) electronic
mail distribution lists, and (d)
communication boards to ensure
existing staff were educated about
the new direction.

Core Councils
Upon identifying the guiding
principles, we determined every
element of nursing practice can be
promulgated into four main categories: clinical, administration,
research, and education (CARE).
Therefore, the middle of our structural dimension signifies the
establishment of CARE councils at
the organizational and unit level.
Representatives from nursing
leadership and bedside nurses are
engaged in the CARE councils.
The following examples depict
how various nursing considerations may be categorized and
divided among the established
council structure.
1. The Clinical council tackles
issues such as devising/revising clinical policies and procedures, clarifying the scopes of
service for practice settings,
and developing guidelines for
staffing, making assignments,
and documenting patient acuity. This councils focus is clinical in nature but frequently
overlaps with other CARE
domains. For example, if a
clinical need is identified that
requires the outlay of financial

resources, the council may

refer their recommendation to
the Administration council.
The council was initially
chaired by a nursing director
but it did not take long to
engage a frontline staff nurse
to assume leadership for the
council, while the director
assumed the role of facilitator.
2. The Administration council,
as its name implies, focuses on
administrative issues such as
strategic planning, reporting
structures, finances, management style, dress code, and
employee and patient satisfaction outcomes. All nursing
directors participate in this
council on a monthly and asneeded basis. The CNO chairs
this council and frequently
invites representatives from
other disciplines to attend
meetings to discuss interdisciplinary concerns. This council
also refers many items to other
CARE councils for discussion
and recommendations and creates special task forces as necessary. For example, during a
review of patient satisfaction
results, the council identified
a problem with patients being
without food or drink for
extended periods because they
were awaiting a test. This issue
was referred to the Clinical
council for exploration, and
evidence-based
guidelines
were developed. Another
example is when the council
identified a problem with
rejected laboratory samples
and relationship problems
between laboratory and nursing. This led the council to
sponsor a Nurse-Lab council to
specifically work on these
opportunities for improvement.
3. The Research council is
focused on identifying questions pertinent to nursing for
which there are no readily
available answers. Perhaps no
work has been done within the
nursing profession to address

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the question or the organization has not yet searched the

available literature to find an
answer to the question. This
council is dedicated to progressing the practice of nursing and the profession of nursing. This council works to
ensure the availability of
library services and online
databases, educate staff about
the conduct of research, seek
reliable evidence to improve
practice, search for grant
opportunities to support nursing initiatives, and disseminate internal and external
research findings. Like the
other CARE councils, this
council gives recommendations to other councils and is
frequently called upon to provide guidance. The council is
chaired by the nursing
research coordinator with the
goal of mentoring a frontline
staff nurse into the leadership
role.
4. The Education council is concerned with both patient and
employee educational needs
and the evaluative methods
used to determine if our educational efforts are effective.
Examples of work conducted
within this council include
devising patient educational
materials and ensuring effective education for staff when
rolling out a new program.
This council frequently asks
for frontline input to determine if educational programs
are effective and user friendly.
To ensure that frontline staff
may express educational
needs, the council created an
Educational Needs Log that is
maintained on every nursing
unit. Any staff member who
identifies an educational need
may use the log to document
their recommendations for
educational
opportunities.
The council was initially
chaired by a nursing director
but transitioned to a nurse
manager. The goal is to transi-

173

tion leadership to a frontline

staff nurse.
The unit-based councils address all CARE elements or refer
issues to the organizational CARE
councils as necessary. Likewise,
the organizational CARE councils
may defer issues to the unit-based
CARE councils. To ensure that the
organizational CARE councils and
unit-based councils are coordinating efforts effectively, a CARE
Coordination Council was established. The CARE Coordination
Council ensures the flow of information between unit-based councils and organizational CARE
councils and also facilitates effective collaboration with other interdisciplinary committees. This
council meets monthly and invites different CARE councils,
both organizational and unit, to
present on their work in progress
and outcomes.

Model of Care
The core of the structural
dimension identifies our chosen
model of care: patient-centered
care. Patient-centered care (PCC)
is defined by the Institute of
Medicine (2001) as providing
care that is respectful of and
responsive to individual patient
preferences, needs, and values
and ensuring that patient values
guide all clinical decisions (p.
40). As part of our structure, nursing established an interdisciplinary steering committee to assist
in achieving our mission of providing PCC that exceeds patient
and family expectations. The PCC
Steering Committee is chaired by
the CNO. Interdisciplinary membership includes representatives
from areas such as patient satisfaction team leaders (physician, inpatient, emergency department,
operative services, recruitment
and retention, and ambulatory
services), nursing (management
and non-management), physicians, administration, arts in medicine, chaplaincy, ancillary services, support services, case management, and human resources. Staff

174

members are educated about the

tenets of PCC during orientation
and annual mandatory training.

PROCESS DIMENSION
After developing a strong
structural foundation, we identified the various internal and external processes that influence our
practice. The key processes
include (a) regulatory and professional standards; (b) performance
improvement, evidence-based practice, and nursing research; (c)
BEST initiative; (d) participatory
management; and (e) the eight
dimensions of PCC.

Regulatory and Professional

Standards
The first element of the
process dimension reinforces the
importance of adhering to regulatory and professional nursing
standards including (a) delegation
(American Nurses Association
[ANA], 2005a; Florida Nurse
Practice Act, 2008); (b) documentation (ANA, 2005b); (c) ethical
practice and research (ANA,
2001); (d) nursing process (ANA,
2004; Florida Nurse Practice Act,
2008); and (e) staffing (ANA,
2005c). Some additional key
processes gleaned from The Joint
Commissions National Patient
Safety Goals (2009) include (a)
patient identification, (b) communication, (c) medication safety and
reconciliation, (d) fostering patient involvement in care, and (e)
reduction of risk, including falls,
suicide, influenza, pneumococcal
disease, and health care associated
infections and pressure ulcers.
Nursing is also committed to
meeting the standards of excellence as outlined by the American
Nurses Credentialing Center
(ANCC, 2008) and specialty-specific nursing standards. Some of
the key processes included in
these standards, not already
addressed above, are (a) budget
development, (b) interdisciplinary
collaboration, (c) decision making,
(d) fiscal and resource allocation,
(e) leadership, (f) mentoring, (g)

peer review, (h) performance

appraisal, (i) privileging and credentialing of advance practice
nurses, (j) professional development and competency, and (k)
succession planning.
Several strategies are utilized
to hardwire these processes in
practice. A few strategies include
(a) audits conducted by both internal and external experts; (b) staff
education via self-study modules,
orientation, competency reviews,
and annual mandatory education;
(c) policies and procedures; (d) job
descriptions; (e) web site postings;
and (f) support from quality management personnel and the patient
safety officer (who is a nurse).

Performance Improvement,
Evidence-Based Practice, and
Research
The second element of the
process dimension speaks to our
commitment to improving nursing
performance and advancing the
practice of nursing. We realize it is
no longer acceptable to support
our practice based on ideas such
as we have always done it that
way. By using well-defined
processes for research and evidence-based practice, such as
The Iowa Model of EvidenceBased Practice to Promote Quality
Care (Titler et al., 2001) and the
ethical review of all research by
the institutional review board, we
are able to contribute to nursing
knowledge, innovations, and the
achievement of quality outcomes.
One example of using innovation and research to improve quality outcomes is the One Call
STEMI research study currently
underway. Prompt reperfusion is
essential for patients experiencing
STEMIs (ST-segment elevation
myocardial infarctions). Our prior
process included a call being
placed to an access center then to
the transfer desk, staffed by nonclinical employees. A blast page
was then sent to the catheterization laboratory team and interventionalist who then returned the
call to the non-clinical staff. In

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this process, critical information

could be lost and/or miscommunicated causing unnecessary delays
in transfer of care and treatment.
The study examines the strategy of
a one call activation process for
STEMI emergencies to expedite
patient placement, transportation,
and treatment as facilitated by
critical care nurses. The critical
care nurse provides real-time
information using a smart-phone
and WAP (wireless application
protocol) technology. They also
activate the STEMI stat system
when indicated, or facilitate communication between key providers such as the cardiologist on
call and emergency medicine
physicians. WAP technology allows many of the switchboard
functions previously requiring a
personal computer to be performed using a wireless device.
Using the same technology, the
critical care nurse can receive
incoming information from other
team members regarding their projected arrival time, traffic delays,
etc. While performing these tasks,
the nurse can also be at the
patients bedside and expedite
transfer to the cardiac catheterization laboratory. The nurse can
relay critical clinical information
from the bedside and assist with
the triage of patients who are
appropriate to go directly to the
lab versus those who may need
further evaluation. Currently, we
have improved and maintained
our door-to-balloon times below
the 90-minute target and are now
moving to field activation.
Additionally, by utilizing a
performance improvement methodology such as IMPACT CARE, we
measured and improved processes
and outcomes systematically.
IMPACT CARE embraces the philosophy of continuous quality
improvement and incorporates
tools for departmental use. Each
unit/department has an IMPACT
CARE spreadsheet tool that provides action plan templates, control charts (automatically graphs

the data being tracked), and an

annual appraisal. IMPACT CARE
is an acronym which means:
I Identify. Employees come
together in a particular department or work group to identify
key customers, scope of care or
services, key activities, organizational goals, quality improvement
goals, cost, satisfaction, survey
results, and other indicators to
monitor performance.
M Monitor. Once identified,
indicators are monitored over
time.
P Prioritize. Using collected
data, the department or work
group prioritizes opportunities for
improvement based on quality
and patient safety processes and
systems, outcomes, impact on
service, and cost. Goals are set
when data show an opportunity to
improve.
A Action plan. Create an
action plan and implement to
achieve stated goals.
C Check. Analyze data to
assess effectiveness of action
plans.
T Transform. Once the
improvement is achieved, the
process is institutionalized or generalized to benefit more areas of
the organization.
And why do we do this?
C To enhance customer satisfaction
A To achieve improved outcomes
R To reduce cost
E To enable employee ownership
Some of the ways in which we
ensure these processes are effective are through (a) leadership
evaluation manager software used
to track leadership performance
against annual goals; (b) quality
dashboards for tracking and trending; (c) staff education (journal
clubs, instructional classes, simulation, and case study investigations); and (d) policies and procedures (e.g., number of updates/
changes in practice based on
research).

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Participatory Management
Participatory management is
perhaps the most important element in the entire SJMC
Professional Practice Framework
for Nursing because a participatory work environment has been
linked with increased nurse satisfaction and improved retention
(George, 1997; Hastings, 1995;
Reif, 1995; Weisman, Gordan,
Cassard, Bergner, & Wong, 1993)
and higher patient satisfaction
(Vahey, Aiken, Sloanne, Clarke, &
Vargas, 2004). Likewise, improved
nurse retention leads to better
patient outcomes (Scott, Sochalski,
& Aiken, 1999).
There are two basic tenets to the
SJMC Participatory Management
Model. The first tenet is the expectation management will adopt a
servant-leadership style. In servantleadership, management changes
its style from an autocratic orientation to a servant orientation by
demonstrating behaviors that lead
to staff collaboration, trust, and
advocacy. The second tenet of our
model is the expectation that
frontline staff will engage and participate in decision making if
offered the opportunity to do so.
Staff become owners instead of
renters (Studer, 2003, p. 167) in
an effective participatory environment.
The CNO has educated all
nurse leaders regarding the characteristics of servant leadership
and a participatory work environment in support of the first tenet.
In support of the second tenet,
numerous CARE councils are
available at the organizational and
unit levels that provide opportunities for frontline staff to engage in
decision making. Staff may accumulate significant points towards
the professional recognition program (see Table 1) by participating
in councils.

Eight Dimensions of PatientCentered Care

After identifying PCC as our
basic model of care, we searched

175

Table 1.
Reward and Recognition Program Descriptions
Program
Customer Service Is Key Award

Employees may be nominated for a Key Award by peers, management, patients,

and/or families for going above and beyond. The employee receives recognition
in a public way such as at a staff meeting or committee meeting. A small key and
a key holder are given to the employee that he/she may wear. On a quarterly basis,
all nominations are put into a drawing and winners receive a party in their department and a gift card.

Caught in the Act of Caring Coupon

Employees may receive on the spot recognition for doing something special. In
addition, employees are eligible for three coupons for floating to work on another
unit than their normal assignment. Coupons may be redeemed for gifts. The more
coupons, the greater the gift. Peers, management, patients, and/or families may
give any employee a coupon. Patients receive coupons in their admission packet
so they may recognize staff members who provide great customer service.

Thank You Note Campaign

This is an informal way that co-workers and management may recognize each
other for something that deserves a little bit more than just a verbal or electronic
mail thank you. A personalized note is sent to the employees home address and
is a nice surprise when he/she opens the mail.

Professional Recognition Program

This program is designed to encourage bedside nurses to join in the effort to

advance the practice of nursing. Annually, bedside nurses may accrue points for
various activities such as achieving an advanced degree, obtaining professional
certification, participating in nursing research, attending councils, etc. If enough
points are accrued, the nurse may receive a monetary bonus.

Charge Nurse Development Program

Annually, the organization sponsors a special event for charge nurses. The program includes an educational element, fun activities, and food. During the program, charge nurses are praised for their contributions and rewarded with a paid
day away from their usual hectic work pace.

for a PCC model with more specificity to refine our efforts and
came upon NRC Picker. NRC
Picker has conducted extensive
interviews of thousands of
patients, family members, physicians, and hospital staff to arrive
at eight common themes that are
important to patients and families
including (a) access to care; (b)
respect for patients values, preferences, and expressed needs; (c)
coordination and integration of
care; (d) information and education; (e) physical comfort; (f) emotional support and alleviation of
fear and anxiety; (g) involvement
of family and friends; and (h) continuity and transition (NRC Picker,
2008). We found that NRC Pickers
Eight Dimensions of PatientCentered Care (NRC Picker, 2008)
complimented our BEST initiative
while encouraging the establish-

176

Description

ment of additional processes to

assist us in achieving our patientcentered mission and associated
strategic outcomes.
This section elaborates on the
eight dimensions of PCC (NRC
Picker, 2008) and provides examples of our processes to create
patient-centeredness.
1. Access to care. Patients want
access to care when they need
it. Some of our processes for
this dimension are (a) throughput initiatives to provide timely access to hospital beds; (b)
outreach programs and clinics;
(c) timely access to consults,
treatments, and diagnostics;
(d) outpatient pharmacy; (e)
expert resources, such as diabetes educators and wound
care nurses; and (f) case management services which link
patients with community re-

sources and financial assistance.

2. Respect for patients values,
preferences, and expressed
needs. Patients indicate a need
to be recognized and treated as
individuals. They are concerned with their illnesses and
conditions and want to be kept
informed and involved in their
care decisions. Patients deserve to be treated with dignity
and respect. Some of our
processes for this dimension
are (a) BEST Behaviors and
Code of Conduct; (b) individualized care that is considerate
of their culture, values, preferences, and needs; and (c) living wills and advance directives.
3. Coordination and integration
of care. Patients report feeling
vulnerable and powerless in

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the face of illness and the

proper coordination of care
can ease those feelings. Some
of our processes for this
dimension are (a) case management services to assist with
coordination of needs once
patients are discharged, (b)
interdisciplinary plan of care
and rounding, and (c) educating our patients and their
loved ones about the plan of
care.
4. Information and communication. Patients express fear that
information is being withheld
from them and staff is not
being completely honest about
their condition or prognosis.
Some of our processes for this
dimension are: (a) A-I-D-E-T
(acknowledge, introduce, duration, explain, and thank you)
scripting and patient information boards, (b) interdisciplinary plan of care, (c) interdisciplinary patient education
record, (d) language and interpreter services, and (e)
informed consent.
5. Physical comfort. The level of
physical comfort patients
report has a tremendous
impact on their experience.
Some of our processes for this
dimension are: (a) hourly
rounding to include the three
Ps (pain, position, and potty),
(b) pain assessment and
reassessment, and (c) nutritional consultation as needed
to meet the patients individual needs.
6. Emotional support relieving
fear and anxiety. Fear and anxiety associated with illness can
be as debilitating as the physical effects. Some of our
processes for this dimension
are (a) chaplain services for
spiritual support, (b) arts in
medicine
programs
(art,
music, pet therapy, etc.), (c)
palliative care interventions,
and (d) hospice referrals and
interventions. A new initiative
under development is the use
of Reiki.

7. Involvement of family and

friends. Patients continually
address the role of their family
and friends, and often they
express concern about the
impact illness has on family
and friends. Some of our
processes for this dimension
are (a) identified family
spokesperson; (b) visitation
policy; (c) involvement of the
patients significant others in
care coordination, education,
and discharge planning; and
(d) patient and family activated rapid response team.
9. Transition and continuity.
Patients often express considerable anxiety about their ability to care for themselves after
discharge. Some of our
processes for this dimension
are (a) home health services,
(b) case management services,
(c) ambulatory services, (d)
medication reconciliation, (e)
hand-off communications, and
(f) referrals to needed community resources.

BEST Initiative
The third element of our
process dimension pertains to the
BEST Initiative, a program
derived from the Studer Group
aimed at achieving a high level of
performance in five pillars of
excellence: service, people, quality, finance, and growth (Studer,
2003, p. 28). BEST is an acronym
for Building Excellent Service
Together. Examples of nursing
activities associated with the
BEST initiative and each pillar
include:
1. Service levels are improved by
using tools such as AIDET
scripting (acknowledge, introduce, duration, explain, and
thank you), hourly rounding,
key words at key times, and
informational white boards.
Work in this area is congruent
with our mission of achieving
excellence in PCC.
2. People activities are focused
on employee rewards and
recognition. Nursing partici-

NURSING ECONOMIC$/May-June 2010/Vol. 28/No. 3

pates in all reward and recognition programs established by

the organization such as:
Customer Service Is Key
awards, Caught in the Act of
Caring Coupons, and Thank
You Note Campaign. In addition, nursing implemented a
professional recognition program to monetarily reward
bedside nurses for exceeding
job expectations. Other activities include recognition in the
Nursing Notes newsletter, special events such as the Charge
Nurse Development Program,
etc. See Table 1 for a description of these programs.
3. Quality efforts are focused on
improving outcomes on nursesensitive indicators, including
but not limited to (a) pressure
ulcer prevention, (b) nosocomial infection prevention (e.g.,
ventilator-associated pneumonia, central venous line infections, and urinary tract infections), (c) fall prevention, and
(d) influenza and pneumococcal vaccinations.
4. Finance management is critical within the nursing division
because nursing care is one of
the most costly expenditures
for the organization. Nursing
uses a variety of tools to manage human, supply, and equipment resources. For example,
nursing monitors productivity
against established targets on a
daily basis. These targets are
established each year by considering the previous years
actual experience, comparing
actual against national benchmarks from the University
Health Consortium and the
National Database of Nursing
Quality Indicators (NDNQI),
and evaluating service and
quality indicators at the unit
level. Nurse managers receive
an electronic report daily
demonstrating unit-level performance against targets.
Budgetary performance is
evaluated monthly, and both
positive and negative vari-

177

ances are investigated and

explained. When targets are
not met and a justifiable reason for a variance is absent, an
action plan is devised and
implemented to correct the
variance going forward.
6. Growth activities are focused
on growing our own and
growing our organization.
Growing our own entails professional development activities pertaining to competency
and skill enhancement, continuing education, and support for professional certification and academic progression. Growing our organization entails the efficient
throughput of patients to
achieve organizational volume
targets. Nursing has implemented many processes to
improve patient throughput.
For example, nursing implemented an electronic patient
tracking system to manage the
flow of patients throughout the
continuum of care. Nursing
also established a house-wide
census monitoring process via
a paging system and daily bed
meetings to facilitate the timely placement of patients when
capacity is challenged by
demand.

OUTCOMES DIMENSION
This dimension outlines the
strategic plan for nursing by stating the strategic intents that are
supported by the structure and
process dimensions of our framework. Our strategic outcomes are
organized using the BEST pillars
of excellence (Studer, 2003), and
for each strategic intent we have
established a reliable way to measure and evaluate our established
professional practice framework.

Service Priorities
Patient/family satisfaction with
nursing care. Patient and family
satisfaction are measured monthly
using the services of Professional
Research Consultants, Inc. (PRC).
Patients are surveyed, via tele-

178

phone by PRC on a random basis,

to ascertain their level of satisfaction with various elements of care.
Survey results are readily available to nursing via the PRC web
site, and we compare our performance against other PRC-affiliated
organizations. Scoring very
good is not good enough for us.
The achievement of excellence is
the only score considered acceptable by our organization. Monthly
and year-end results are presented
each month throughout the organization demonstrating unit and
overall results. The board of directors also reviews patient satisfaction outcomes. Nurse leaders are
evaluated, during annual performance reviews, on their unit, division, or organization performance,
as appropriate to their scope of
responsibility.
Significant involvement in
community initiatives. Nursing
believes that its responsibilities
for improving the health and wellbeing of others extend beyond our
daily work. By getting involved in
our community, we believe nurses
reap personal and professional
rewards, and our community benefits through improved health outcomes. To determine success on
this strategic intent, we track staff
and management participation in
community events. There are no
established benchmarks to use as
a comparison; therefore, we compare our performance against previous performance and continually strive to increase community
contributions.
Image. The image of nursing,
specifically how nursing is perceived by others, is an important
gauge for evaluating the achievement of nursing excellence. We
evaluate our overall progress
towards achieving this strategic
intent using internal and external
validation methods. Internal validation of excellence is measured
by conducting various surveys of
other disciplines and even surveying our own nursing staff periodically to ascertain the perception of
nursing excellence. When possi-

ble, we compare our performance

against the performance of other
nursing divisions. If comparative
data are not available, we compare
performance to previously conducted survey results within the
organization.

People Priorities
Recruitment and retention.
The recruitment and retention of a
qualified and committed nursing
workforce has been linked to
improved nursing and patient outcomes (Newman, Maylor, &
Chansarkar, 2001). We measure
three primary indicators periodically to determine performance:
turnover, vacancy rate, and
employee satisfaction. The first
two indicators may be compared
regionally and nationally using a
variety of sources, such as our
state hospital association and the
American Nurses Credentialing
Center respectively. Nurse satisfaction is measured by conducting
annual surveys of our bedside
nurses using the NDNQI RN
Survey with Satisfaction. Key
areas measured include (a) job satisfaction, (b) job enjoyment, (c)
work context items, (d) job plans,
and (e) RN characteristics. Findings from the survey allow for
benchmarking against similarsized hospitals/units at a national
level and drill down on specific
indicators to the unit level.

Quality Priorities
Quality outcomes. Nursing
identifies priority nurse-sensitive
goals annually for the entire nursing division and at the unit level.
Nursing dashboards are used to
monitor performance against comparative benchmarks at the highest level possible, such as
NDNQI, National Healthcare
Safety Network, and University
HealthSystem Consortium. Dashboards are essentially a way to get
an at-a-glance understanding of
the metrics of importance to nursing and act as a way of summarizing and highlighting specific outcomes. Dashboards also improve

NURSING ECONOMIC$/May-June 2010/Vol. 28/No. 3

communication and promote

accountability by presenting information in an easy-to-read format
that allows translation and trending of data to drive strategic performance excellence. Nursing
dashboards are maintained at an
organizational level for all of nursing and also at the department/
unit level. Some of the items
included on the organizational
dashboard include (a) supply and
salary expenses, (b) turnover rates,
(c) patient satisfaction, and (d)
quality indicators (e.g., falls, pressure ulcers, restraints, health care
associated infections, vaccination
rates).
Patient-centered and safety
culture. The establishment of a
PCC environment is not only conducive to improved patient satisfaction outcomes but also congruent with improved clinical outcomes and reduced medical errors
and/or omissions (IOM, 2001).
We determine progress towards
achieving patient centeredness
and safe patient environments by
measuring patient perception on
numerous PRC survey questions.
In addition, we conduct an annual
culture of safety survey utilizing
the Agency for Healthcare
Research and Quality Hospital
Survey on Patient Safety Culture.
This survey is offered to all staff
and is designed to help hospitals
assess the culture of safety in their
organizations. Furthermore, our
success in achieving a culture of
safety is measured via a variety of
quantitative methods including,
but not limited to, falls prevalence, compliance with medication reconciliation, and hand
hygiene.
Integrated information management. The ready availability
and quality of information available to nurses can directly affect
the quality of care provided
(Currell & Urquhart, 2003). SJMC
is currently phasing in an integrated information management system (IMS) that will eventually
lead to a fully automated and
paperless medical record. Some of

the IMSs already used by nursing

include an event management system, an electronic competency
tracking system, a staffing and
payroll system, and a patient
tracking system. Outcome measures utilized and consistent with
those reported in the literature
include (a) system quality, (b)
information quality, (c) usage, (d)
user satisfaction, (e) individual
impact, and (f) organizational
impact (van der Meijden, Tange,
Troost, & Hasman, 2003).

Finance Priorities
Optimization of financial resources. Nursing measures its success on this initiative by evaluating performance against budgets
at the organizational and unit levels as previously described. In
addition, nursing tracks its efforts
and associated successes to secure
alternative funding sources, such
as grants, to support patient care
and employee development programs. Lastly, we track the savings
that occur each year as the result
of nursings efforts to contain or
reduce costs. Nurse leader financial performance is evaluated during annual performance reviews.

Growth Priorities
External validation of excellence is measured in a number of
ways. We measure the level of formal academic achievement and
the attainment of professional certifications for members of the
nursing workforce. National
benchmarks are available for comparison. We evaluate nursings
performance on external accreditation surveys (e.g., The Joint
Commission, state surveys, etc.).
We track acknowledgments of
nursing best practices via participation in local, state, and national
conferences and the acceptance of
written work for journal publications. Lastly, we gauge performance via the achievement of organizational certifications, recognitions, and awards such as the
Florida Governors Sterling Award
(which we received in 2008), and

NURSING ECONOMIC$/May-June 2010/Vol. 28/No. 3

the U.S. Department of Health and

Human Services Organ Donation
Medal of Honor (received in 2005,
2006, 2007, and 2009).
Efficient throughput. Nursing
is instrumental in the efficient
flow of patients due to the critical
role that we play in admission,
discharge, and transfer processes
on a continuous basis. Numerous
indicators are tracked to determine performance: turnaround
time for treating and releasing
patients from the emergency
department, number of patients
left without being seen from our
emergency department, turnaround time for assigning an inpatient bed after receiving a request,
turnaround time for placing
admitted patients in a bed, etc.
Perhaps the most significant outcome measure in this area is
whether the organization meets
budgeted volume targets.

LESSONS LEARNED
Since the implementation of
our three-dimensional framework,
we have learned many valuable
lessons. From a structural perspective, we learned that creating a
structure to support nursing in a
large organization is easier to construct on paper than to achieve. We
uncovered unit-based councils
working on issues that are not unitspecific but rather global in nature
and perhaps better suited for an
organizational CARE council to
address. We encountered confusion over which organizational
CARE council should address
which issues due to overlapping
interests (is the matter predominantly a clinical issue or an administrative issue?). We are now implementing specific annual goals for
each council to ensure focus, better
communications horizontally and
vertically, and the achievement of
annual results by each council
instead of councils lingering simply as communication forums
without the production of results.
Furthermore, each council is now
required to disseminate information about work in progress and

179

achievements throughout the year

via the CARE Coordination Council and produce an annual evaluation.
From a process perspective,
our most significant challenge has
been the achievement of a truly
participatory milieu. We have
found it a struggle to consistently
achieve a high level of representation from frontline nurses at council meetings due to scheduling
and staffing concerns taking priority over council participation. We
found continuity in participation
to be especially difficult to
achieve because most bedside
nurses only work 3 days a week,
and most nurses are not willing to
come into work on their day off for
a 1-hour council meeting. We
knew when we adopted a participatory management model it
would be a journey instead of an
event. We continue to coach our
nurse managers on how to inspire,
lead instead of manage, and advocate effectively for frontline nurses. We continue to coach our
frontline nurses on how they can
become part of the solution if they
will seize opportunities to participate in decision making and how
participation will benefit them.
From an outcomes perspective,
we ultimately gleaned perhaps it
would have made more sense for
nursing to identify desired outcomes or strategic intents first and
then back into our process and
structural dimensions. While this
may sound nonsensical and perhaps not the way Donabedian
(1980) intended his model to be
used, we might have avoided some
missteps along the way if we
would have reversed our development process. Does it not make
sense to determine where you want
to be first and then identify the best
route to get there?

CONCLUSION
Although adopting an offthe-shelf professional practice
framework for nursing may sound
easier for a nursing organization
than creating its own framework,

180

achieving a good fit into an existing culture is more difficult when

adopting rather than creating a
practice framework as we did.
Even though creating a customized framework requires a
considerable amount of upfront
time, dedication, and a willingness to make some mistakes along
the way, in the end a customized
framework does ensure cultural
alignment. The framework describes our foundational structures and guiding principles, the
key processes that influence how
we conduct our work, and the outcomes desired as the result of our
work. Identifying evaluative methods for determining progress, for
identified strategic intents, was
crucial to bridge the gap between
theory, Donabedians SPO Model
(1980), and the achievement of
measurable outcomes.
In conclusion, our threedimensional approach, using
Donabedians SPO Model (1980),
met the prerequisites we identified as being important: (a) complimented work already in
progress, (b) supported frontline
nurses, and (c) easy to understand.
Furthermore, support for using
Donabedians SPO Model (1980)
to guide nursing practice was
gleaned from the literature. Recent
changes in the ANCCs Magnet
Recognition Program (2008) also
support a structure, process, and
outcome format. This model continues to provide flexibility and
adaptability to meet our needs in a
constantly changing health care
environment and difficult economic times. $
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