Registered nurses make measurable contributions to the health and wellness of persons living in nursing homes. However, most nursing homes do not employ adequate numbers of professional nurses with specialized training in the nursing care of older adults to positively impact resident outcomes. As a result, many people never receive excellent geriatric nursing while living in a long-term care facility. Nurses have introduced various professional practice models into health care institutions as tools for leading nursing practice, improving client outcomes, and achieving organizational goals. Problematically, few professional practice models have been implemented in nursing homes. This article introduces an evidence-based framework for professional nursing practice in long-term care. The Everyday Excellence framework is based upon eight guiding principles: Valuing, Envisioning, Peopling, Securing, Learning, Empowering, Leading, and Advancing Excellence. Future research will evaluate the usefulness of this framework for professional nursing practice.
Despite the many structural and social changes in the long-term care of older adults over the past century, one constant remains: in every nursing home in America, there are people who would benefit from the knowledge, skills, caring, and leadership of professional nurses. Today people who live in nursing homes have more health problems and need greater assistance with activities of daily living than those of past generations (Gabrel, 2000; Jones, 2002; Sahyoun et al., 2001). Researchers have shown that registered nurses (RNs) make a measurable difference in the health outcomes of older persons. When RNs care for people living in nursing homes, fewer restraints are used, residents develop fewer infections, and they are admitted to hospitals less often (Castle & Fogel, 1998; Pekkarinen et al., 2006; Sullivan-Marx et al., 1999, Zimmerman et al., 2002). From an organizational standpoint, nursing homes that employ larger numbers of RNs receive fewer deficiencies on annual surveys (Harrington et al., 2000b) and are involved in fewer lawsuits (Johnson et al., 2004). Job turnover among RN staff is associated with worsening of quality of care measures for residents (Castle & Engberg, 2005). Without the leadership of professional nurses, people living in nursing homes suffer many negative consequences, such as pressure ulcers (Hickey et al., 2005; Kayser-Jones et al., 2008), unexpected weight loss (Bostick, Rantz, Flesner, & Riggs, 2006), increased urinary catheterization, and a decline their ability to complete activities of daily living (Horn, Buerhaus, Bergstrom, & Smout, 2005).
Yet, in most nursing homes, the professional nurse is an endangered position. Registered nurses make up a small percentage of the total number of direct care workers in nursing homes (Harrington, O’Meara, & Kang, 2006). Many of these RNs are in administrative positions with little day-to-day contact with residents, families, and caregiving staff. Further, most professional nurses in nursing homes have not received specialized training in the care of older adults. The director of nursing often has not earned a bachelor’s degree or received training in organizational leadership or business management (Mueller, 2002a; Tellis-Nayak & Duss, 2005). As a result, nursing home residents often do not experience the health outcomes they might achieve if they received excellent geriatric nursing care from professional nurses (Mueller, 2002b; Wells, 2002). In recent years, excellence in elder care has become a recurring theme in the gerontological literature (Deutschman, 2001a/b; Fulmer, 2000; Regenstreif, Brittis, Fagin, & Rieder, 2003). This paper introduces Everyday Excellence as a framework for professional nurses interested in establishing excellence in long-term care settings.
Professional practice models (PPM) empower registered nurses to deliver higher quality health care by changing how nursing care is provided in an organization. Hoffart and Woods (1996) called professional practice models “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). When RNs implement a PPM in an organization, they create an innovative system for career advancement (O’Hara, Duvanich, Foss, & Wells, 2003) and influence healthcare policy and practice at the institutional level (Hastings, O’Keefe, & Buckley, 1992). Among the organizational benefits of PPMs are improved patient care outcomes and a modest savings in some cost effectiveness measures (Hoffart, Schultz, & Ingersoll, 1995; Witzel, Ingersoll, Schults, & Ryan, 1996). While most PPMs achieve similar goals, it is important to note that the formats that these innovations assume in clinical settings are always site specific and context driven (Hastings, 1995; Hastings & Waltz, 1995; Horvath, 1990; Jones & Ortiz, 1989; Rose & DiPasquale, 1990; York & Fecteau, 1987). However, while PPM formats differ between healthcare institutions, most researchers report that registered nurses experience more autonomy and control over nursing practice, increased job satisfaction, and lower turnover, following the implementation of a professional nursing practice in their facilities (Hoffart, Schultz, & Ingersoll, 1995; Mark, Salyer, Wan, 2003; Specht & Maas, 2006).
While registered nurses have implemented PPMs in acute care hospitals, few comparable efforts have been made in long-term care. However, two exemplars of professional nursing practice in extended care environments suggest the potential benefits of such models in nursing homes. The first is a professional nursing model instituted during the 1960s–70s by Lydia Hall and colleagues at the Loeb Center for Nursing and Rehabilitation at Montefiore Hospital and Medical Center in New York City. Over a 15-year period, registered nurses in this facility shifted from a task focused “caretaking” perspective to a professional orientation that emphasized the healing role of registered nurses (Alfano, 1971, p. 275). Personal qualities cultivated among the nurses included self-direction, self-awareness, professional judgment, creativity and intelligence paired with basic knowledge, and a service ideal. Professional behaviors asserted by the RNs included a primary patient-centered focus of care with 24-hour accountability, dynamic action responsive to patient needs rather than institutional routines, nurse-to-nurse peer relationships, a teaching orientation, and the “capacity to re-perceive knowledge and/or rearrange it to develop new theory” to improve patient care. Organizational capacities expanded to create a “liberating system which fosters democratic care” including programs to support the practice transfer and implementation of nursing knowledge, clinical recordkeeping systems to document nursing care practices and monitor health outcomes, and forums to enhance interdisciplinary communication and cooperation (Alfano, 1971, p. 273–280). Registered nurses working within this professional model gained confidence in their clinical skills and leadership abilities (Bowar, 1971). As one nurse wrote, “Here the nurse is the unifying member of the health team. In fact, at Loeb nursing is the chief therapy experienced by our patients; medicine and allied disciplines are supportive services” (Englert, 1971, p. 281).
The second example of professional nursing practice from long-term care is the nursing shared governance model implemented at the Iowa Veterans Home (IVH) in Marshalltown, Iowa (Maas, 1989; Maas & Specht, 1990). Prior to implementation of shared governance, authority for resident care rested with physicians and the administrator rather than the nursing staff. The few RNs employed by the facility had little input into day-to-day resident care practices, long-range care planning, or institutional policymaking. While IVH philosophy espoused “a belief in humanistic care” in actual practice, resident care was “mostly custodial in nature” with routine and staff convenience taking precedent over residents’ needs and preferences (Maas, 1989, p. 67). A nursing shared governance model was designed to achieve three goals: 1) maximizing the clinical functions of registered nurses; 2) creating an organizational environment that fostered the professional development of registered nurses; and 3) developing an organizational culture that facilitated the clinical decision-making of registered nurses. To attain these goals, the RNs often met as a group to discuss resident care and practice issues, to learn from one another’s expertise, and to create a shared vision of professional nursing and resident care. As Maas (1989) wrote of these meetings, “All nurses had the opportunity and obligation to use their special knowledge in the collective decision-making process” (p. 68). With the strategic leadership of an affirming and supportive director of nursing, the nurses moved from task-focused resident care to a fully enacted shared governance model over four years. The most critical transition the nurses made was a change in their views of nursing. Over time, the registered nurses grew from thinking of themselves as employees who followed other people’s orders to viewing themselves as colleagues who had professional autonomy and accountability for their own clinical practice. After implementation of shared governance, IVH residents experienced improvements in several indicators of quality of care, including a decrease in the use of urinary catheters and physical restraints and a decrease in the prevalence of pressure ulcers and urinary incontinence.
Although nurses develop professional practice models in a particular organizational context, there is some agreement on the constitutive elements of PPMs in general. Hoffart and Woods (1996) noted five key elements, or subsystems, underlying such models: 1) professional values; 2) professional relationships; 3) patient care delivery system; 4) management approach; and 5) compensation and rewards. While similarities among PPMs are important, Hoffart and Woods (1996) also noted that each PPM contains “unique qualities and programs” reflecting the organizational resources, institutional priorities, and professional values of the people who create it (p. 359). Professional nurses may discover the essential components of “their” PPM through designing, implementing, and sustaining the model in its real-world context. For example, Hoffart, Schultz, and Ingersoll (1995) presented a case study of an enhanced professional practice model (EPPM) in a 53-bed rural hospital. The RNs in this facility desired increased autonomy in routine patient care decisions, more collaborative practice with the medical staff, better continuity in patient care, new opportunities for continuing education, and increased compensation and recognition. The nurses collaborated with administrators, physicians, and others on the interdisciplinary team to introduce programs such as standardized admission orders, clinical pathways, and post-discharge follow-ups; a nurse assistant position for the delegation of certain patient care activities; self-scheduling; a new nurse preceptorship program; specialty certification; a peer evaluation process; and nurse-to-nurse consultation. Not all of the programs were successes, but most nurses were proud of their contributions to the EPPM project. As one nurse reported, “I like the things that have developed from EPPM. You’ve given us or showed us how to develop good tools for ourselves” (Hoffart, Schultz, & Ingersoll, 1995, p. 49).
While few studies have examined professional nursing practice in long-term care, key points on the usefulness of professional practice models in nursing are apparent in the literature. First, no single professional practice model will address the varied resident care problems and administrative challenges of all healthcare settings. Second, PPMs are site-specific innovations that registered nurses design, implement, and sustain to address the particular health needs of patients or residents in the organizational context of their workplace. Third, implementation of a nursing practice model takes time, often years, and requires considerable preparation of the organization, the nursing staff, and their interdisciplinary colleagues. Finally, a professional nursing model is not a practice innovation that an administrator or director of nursing can force on nurses. Rather, registered nurses must model professional nursing practice themselves. It is through a full commitment to and everyday involvement in creating and sustaining a nursing practice model that responds to the strengths, needs, and challenges of residents, families, employees, and the organization that RNs become professional nurses.
To develop an evidence-based framework for professional nursing practice in long-term care, the theoretical and research literature on PPMs in nursing was reviewed. The CINAHL, MEDLINE, INDEX MEDICUS, and Google Scholar databases were searched using the terms RN, professional, professional models, practice models, professional practice, autonomy, shared governance, leadership, accountability, and professional development. These search terms were combined with the keywords nursing, nursing homes, and long-term care to narrow the results. Articles were limited to those published in English from 1980 to 2007. Relatively few studies of PPMs for nursing homes were found. Thus, the search was broadened to include examples of PPMs in acute care settings, with relevant articles selected based upon their titles and abstracts.
Manuscripts were read to generate a list of components for a professional practice model for long-term care. Prominent nursing care quality initiatives, such as the Magnet Recognition Program (American Nurses Credentialing Center, 2005) and the Nurse-FriendlyTM Hospital Criteria (Texas Nurses Association, 2005), also were reviewed for potential elements. Additional concepts were drawn from the philosophy and values statements of initiatives to re-imagine elder care in nursing homes, such as those of Eden Alternative (2008), Pioneer Network (2007), American Association of Homes and Services for the Aging (2008), Advancing Excellence in America’s Nursing Homes (2008), Wellspring Institute and its Wellspring Model of Nursing Home Care Quality (Stone et al., 2002), and the Nursing Home Quality Initiative of the Centers for Medicare and Medicaid Services (2008). Salient concepts then were categorized thematically and placed into an evolving PPM framework. Commonalities between these initiatives included resident centered care with a focus on excellence, an articulation of a shared philosophy or values statement, employee-friendly personnel policies, lifelong learning, interdisciplinary collaboration, community involvement, participatory leadership, and quality improvement.
While the relative strengths, weaknesses, and utility of various models were considered, the goal was to generate a range of elements to construct a supple framework on which registered nurses might draw when designing, implementing, and evaluating a PPM in their workplace. The literature suggested that a framework should offer a balanced, yet flexible structure to guide the development of site-specific PPMs. Since the literature noted that the process of implementing and sustaining a PPM evolves in unpredictable ways, this framework should allow for the possibilities of forward momentum, sideway turns, and backward corrections. Finally, the framework selected should symbolize the technological innovation, interdependent relationships, and human ingenuity inherent in a professional nursing practice model. Therefore, the metaphor of the wheel was chosen to illustrate the Everyday Excellence for Professional Nursing Practice in Long-Term Care Framework (Figure 1).
PRINCIPLES OF EVERYDAY EXCELLENCE
The Everyday Excellence Framework envisions excellence as a way of being in the world for registered nurses working in nursing homes. The framework intends that RNs are empowered to enact the professional values, best practices, and caring spirit of geriatric nursing when it is integrated into and supported by the structures and processes of a long-term care organization. An underlying assumption of this framework is that the RNs who work in nursing homes are capable of creating, implementing, and sustaining site-specific professional practice models based upon the eight principles of Everyday Excellence: Valuing Excellence, Envisioning Excellence, Peopling Excellence, Securing Excellence, Learning Excellence, Empowering Excellence, Leading Excellence, and Advancing Excellence (Table 1). While Everyday Excellence provides a common structure for the design and evaluation of professional practice models in long-term care, it is not prescriptive. Each group of registered nurses will imagine a unique vision for professional nursing in their nursing home. Thus, this framework is flexible, evolving, and responsive to the strengths, challenges, resources, and imperatives for the professional nurses and long-term care facilities that adopt it. We envision that professional nurses will use the Everyday Excellence framework to create high quality nursing homes that are resident-centered, family-focused, and employee-friendly. An overview of the principles of Everyday Excellence follows, with the relevant literature highlighted in each dimension.
Everyday Excellence: A Framework for Professional Nursing Practice in Long-Term Care
Principle 1: Valuing Excellence
Professional nurses demonstrate that we value the meaningful work we do with persons who live in long-term care settings by enacting excellence in our everyday nursing practices.
Professional nurses are guided in our nursing practices by important social values and beliefs (ANA, 2003). As individuals, RNs may espouse dissimilar values based upon our social, cultural, religious, educational, family, or personal backgrounds. As professional nurses, RNs also commit to a shared set of nursing values (Hoffart & Woods, 1996; Maas, 1989; Maas & Specht, 1990; Mueller, 2002a). For example, the American Association of Colleges of Nursing (1986) has articulated seven essential values of professional nurses: altruism, equality, esthetics, freedom, human dignity, justice, and truth. Similarly, the American Nurses Association (2001a)Code of Ethics for Nurses outlines professional nursing values such as compassion, commitment, advocacy, responsibility, accountability, and collective action, as well as patients’ rights such as respect for the inherent worth and dignity of humans, universal access to health care, privacy, confidentiality, and protection from harm. In its Scope and Standards of Gerontological Nursing Practice, the American Nurses Association (2001b) asserted that nurses who care for older adults should respect human dignity and uphold elders’ unique qualities; emphasize strengths over weaknesses; assist elders toward self-fulfillment; involve aging persons in decision-making; and provide nursing services that maximize function and quality of life, support independence and interdependence, and transform the social conditions that lead to health disparities.
When people share values, a sense of community and purpose is fostered. The Everyday Excellence principles, therefore, serve as the value system for this framework. However, some individuals or groups of people in any organization may have differing values. Such values may serve as sources of friction or, more importantly, inspire innovation in an institution. Therefore, professional nurses engage in a continual process of discovering, clarifying, and articulating the values important to the people of the organization (Hoffart & Woods, 1995). Key values need to be uncovered, understood, and affirmed prior to any change in the nursing home culture, or its systems and processes. Without values clarification, nursing home stakeholders are not likely to implement the professional practice model fully, nor will the changes in practice contribute to substantial and sustainable improvements in resident care quality.
Principle 2: Envisioning Excellence
Professional nurses envision an excellence in long-term care that is founded on a shared philosophy of caring, reflective of professionally recognized nursing standards, and responsive to resident needs and the strategic goals of the organization.
Professional nurses join together to envision a preferred future of elder care in our organizations. Unfortunately, many RNs have never participated in crafting a nursing philosophy statement, while others work in facilities that do not incorporate professional standards into nursing care policies and decision-making (Mueller, 2002a). In order to create a vision of nursing excellence, professional nurses must articulate a shared philosophy of nursing practice, formalize our thoughts in writing, and measure progress towards this vision through agreed-upon standards of nursing practice (ANA, 2001b). This philosophy of caring guides resident care, determines the goals of the nursing department, prioritizes resource allocation, and sets the standards for the day-to-day operations of nursing services and quality improvement initiatives in the organization (Hoffart & Woods, 1996; Hastings, O’Keefe, & Buckley, 1992; Kane, Palette, & Strickland, 1987; Mueller, 2002). Professional nurses also create a vision for elder care by seeking to understand what residents and their families want from long-term care. Professional nurses then engage in a collaborative process with administrators and other members of the interdisciplinary team to make this vision of excellence a reality.
Principle 3: Peopling Excellence
Professional nurses consider geriatric nursing a desirable, enriching, and challenging clinical specialty and demand positions of responsibility, leadership, and professional excellence in long-term care settings.
Professional nurses recognize the many opportunities offered by the field of geriatric nursing and choose employment in long-term care settings (Harrington et al., 2000a). RNs work with employers to establish personnel policies, staffing standards, innovative partnerships, and compensation packages that enhance our ability to care for the people who live in nursing homes. Personnel policies assure that the most qualified people select and stay with geriatric nursing and make our work an enriching experience. Recruitment and retention initiatives reduce turnover among nursing staff as a way to provide continuity and quality resident care. Scheduling programs are flexible and give direct care staff control over the hours they choose to work without jeopardizing resident care. These policies are designed, implemented, and enforced with the involvement of nursing staff at all levels of the organization (TNA, 2005).
Nursing staffing standards assure that there are sufficient numbers of registered nurses, licensed nurses, and certified nursing assistants to care for residents and their families (Collier, this volume). At the legal minimum, nursing homes guarantee that the facility is staffed with a qualified RN on a 24-hour basis. Total nurse staffing and RN staffing are based on research supporting their relationship to resident and staff outcomes (Bostick et al., 2006; Harrington et al., 2000; Horn et al., 2005). Staffing levels also take into account resident acuity and case mix and are adjusted above the minimum standards as needed (Hickey et al., 2005). Minimum nursing staffing levels are a necessary, but not sufficient condition for the implementation of professional nursing practice. Everyday Excellence envisions a time when nurse staffing is not aimed to meet the minimum standards as required by law but, rather, to optimize the knowledge, clinical skills, caring, and leadership of professional nurses working in long-term care settings.
Innovative practice partnerships assure that every resident and family have 24-hour access to a qualified team of nursing personnel led by a professional nurse who cares for the health, wellness, and well-being of the resident (Anderson et al., 2005). This professional nurse is accountable for the quality of the nursing care provided to the resident during his or her stay, serves as a contact person and information resource for the resident and her or his family and friends, and advocates for the resident within the context of the interdisciplinary team. This professional nurse also coordinates the health and wellness services required by the resident, partnering with a stable contingent of licensed practical nurses and certified nursing assistants who are consistently assigned to a group of residents (Barry, Brannon, & Mor, 2005; Burgio et al., 2004; Dellefield, 2008a; Teresi et al., 1993). This RN collaborates with an advanced nurse practitioner, who serves as a primary care provider for the resident. This nurse practitioner provides acute care services, conducts diagnostic assessments beyond the scope of practice of the RN, and offers input into the resident’s overall plan of care (Bakerjian, 2008; Kane et al., 1989).
Professional nurses also recognize that our workplaces must meet our needs for a healthy balance between professional responsibilities and personal life. Recognizing that employees should be paid a fair wage, professional nurses work with employers to assure that salaries and benefits are competitive with those of workers in other health organizations in the community. All nursing home employees are offered health, disability, and long-term care insurance plans as well as retirement savings programs at reasonable costs. Professional nurses also work with administrators and lobby legislators to guarantee that direct care staff are not required to work mandatory overtime or under unsafe staffing and working conditions.
Principle 4: Securing Excellence
Professional nurses secure excellence in our workplaces by creating care settings that all people experience as healthy, respectful, and safe.
Professional nurses and all nursing home employees deserve safe workplaces (ANA, 2001a). Yet, nursing homes are among the most dangerous workplaces in America (SEIU, 1997). According to the Bureau of Labor Statistics (2001), workers in nursing homes sustain nonfatal occupational injuries and illnesses at rates double those of other occupational groups (13.9 vs. 6.1 injuries and illnesses per 100 full-time employees). Contact with bloodborne pathogens like hepatitis and HIV, exposure to antibiotic-resistant microorganisms like tuberculosis and MRSA, latex allergies, noise exposure, needle-stick injuries, hazardous chemicals, and fire safety violations are but a few of the hazards that healthcare workers face in nursing homes everyday (Occupational Health and Safety Administration, 2008). Although mechanical lifts and adequate staffing help assure safe patient handling and decrease injuries, these practices are not routinely implemented in nursing homes (Evanoff et al., 2003). In addition, long-term care nurses and nursing assistants are at risk for workplace violence, particularly from residents with dementia or psychiatric illnesses (Gates, Ftizwater, & Meyer, 1999; Gerberich et al., 2004). When nursing home employees work in unsafe environments, residents and families are also at risk for injury and illness. Therefore, professional nurses have a responsibility to assure that organizational resources provide the necessary staff, education, and technologies to create safe nursing home environments (ANA, 2001b). To assure that the safety priorities of residents and staff are addressed, professional nurses should assume leadership positions on key organizational decision-making bodies and committees, such as those dedicated to safety, quality assurance, product evaluation, employee wellness, and workplace violence prevention (TNA, 2005).
Principle 5: Learning Excellence
Professional nurses thrive in intellectual climates where lifelong learning is expected, appreciated, and recognized and where this specialized knowledge forms the basis for excellence in professional nursing practice and resident care.
Professional nurses pursue four types of learning: personal enrichment, employment-based learning, leadership training, and professional development. Professional nurses recognize that people who achieve learning excellence outside the workplace use those skills, knowledge, and expertise to improve resident care within the workplace. RNs personally commit to learning about the people we serve by reading about gerontology, participating in continuing education to enhance our knowledge of evidence-based nursing, and sharing what we learned with colleagues (ANA, 2001b). Professional nurses also create lifelong-learning environments in nursing homes that support the informational needs of residents, families, and staff (e.g., free access to computers, email, and on-line references). RNs encourage organizations to partner with community resources to assure that all employees achieve basic proficiency in language fluency, basic math skills, and computer and health literacy, and support those who wish to complete a high school equivalency degree. Professional nurses also pursue learning opportunities related to our individual interests.
Professional nurses participate in and lead employment-based learning opportunities (Kane, Palette, & Strickland, 1987). RNs develop institutional commitments that support the professional development of all employees, with educational initiatives to promote formal education, certification, and career advancement evident in the human resource policies, management practices, and annual budget of the organization (ANCC, 2005). Upon employment, nursing department employees participate in a preceptor-guided, unit-focused, and competency-based orientation program (ANCC, 2005; TNA, 2005). Nursing staff also receives cross-unit training prior to work on unfamiliar resident care units. While staff development nurses lead in-service programs and continuing education offerings, each RN commits to educating co-workers, residents, and families about topics that affect human health and wellness. Professional nurses also create academic partnerships with schools of nursing and participation in teaching nursing home projects to increase the nursing staff’s direct access to evidence-based knowledge related to geriatric nursing.
Professional nurses recognize that any person can lead in an organization. Leadership enhancement programs are tailored to meet the learning needs of all nursing personnel, including certified nursing assistants, licensed nurses, and registered nurses. Formal leadership training programs should include content on interpersonal communication, clinical skills, evidence-based practice, and organizational management, as well as ongoing mentorship to develop leadership skills over time (Harvath, Swafford, Smith et al., 2008). Additional leadership training for management and advanced clinical nurses also is encouraged (Dellefield, 2008a). Tellis-Nayak & Duss (2005) found that while directors of nursing were satisfied with their clinical expertise, most were unprepared for their administrative responsibilities, including strategic planning, budget preparation, staffing, and interdepartmental communication. Dellefield (2008) noted similar concerns about leadership training for Minimum Data Set (MDS) coordinators.
Registered nurses continue to develop as professionals through formal education and specialized training (Dellefield, 2008a). Certification as gerontological nurses would benefit most nursing home staff; however, specialization in other areas of geriatric nursing (e.g., rehabilitation; holistic healing; pastoral care; dementia care; wound, ostomy, and continence care; advanced nurse practitioner; health administration; or nursing education) also is encouraged (Maas, 1989).. To role model these expectations, directors of nursing and other advanced clinical or management nurses should earn a bachelor’s degree as a minimum level of educational preparation to support their complex nursing roles.
Principle 6: Empowering Excellence
Professional nurses empower and respect ourselves and one another as vital members of the interdisciplinary healthcare team by joining together in our collective efforts to achieve excellence in resident care.
Professional nurses make a commitment to excellence in nursing care because nursing is a service, not simply a job (Maas & Specht, 1990). We provide continuity in resident care, serve as strong advocates for older adults and their families, and use knowledge to create healthy environments and healing communities. RNs value our professional autonomy and hold ourselves accountable for the decisions we make in our everyday nursing practice (Maas, 1989; York & Fecteau, 1987). RNs make similar commitments in our collegial relationships as well (ANA, 2001a, b; Hoffart & Woods, 1996). We treat all co-workers as trusted colleagues and respected peers, regardless of tenure or organizational title. We respect the unique background, thoughts, beliefs, and outlooks that each person offers the nursing profession. RNs nurture each other and gain confidence in our ability to provide high quality, cost-effective, resident-centered, and family-focused care. Through mutual support and shared accountability, RNs evolve an individual identity and shared consciousness as professionals that bring strength to collective actions (Maas, 1989; Zelauskas & Howes, 1992). Recognizing that no single nurse possesses all the specialized knowledge and skills needed to provide high quality care, professional nurses look to one another as valuable resources. RNs establish forums for open communication, dialogue about professional concerns, and build consensus on nursing practice issues (Alfano, 1971; Hastings, O’Keefe, & Buckley, 1992; Maas, 1989). Professional nurses share the responsibility for gathering and evaluating data and distributing this information to co-workers. Peer consultation is a trusted means by which RNs ensure quality of care and resident safety. Through peer review and evaluation, professional nurses determine the standards of care to uphold and willingly take risks to secure the necessary resources and institutional environment to support these standards (Zelauskas & Howes, 1992).
Principle 7: Leading Excellence
Professional nurses create organizational structures that facilitate collaborative practice and foster nurse leadership of institutional and cross-organizational initiatives to achieve excellence in long-term care.
Professional nurses share the responsibility for leadership in the nursing home (Maas, 1989; Maas & Specht, 1990). RNs volunteer to assist in initiatives to improve resident care quality and nursing practice (Kane, Palette, & Strickland, 1987). RNs serve as preceptors to new employees, teachers to students of nursing, and mentors to colleagues who are engaged in professional development. Professional nurses seek opportunities to mature as leaders in the workplace by taking on appropriate supervisory and management positions on resident care units and throughout the organization (Hastings, O’Keefe, & Buckley, 1992). Professional nurses become visible, vocal, and valuable members of the healthcare team by participating in resident care planning and by serving on interdisciplinary committees in the organization (Kane, Palette, & Stickland, 1987; Pierce, Hazel, & Mion, 1996). RNs also expand our influence outside the workplace through involvement in professional associations, community service projects, and political activities (ANA, 2001a).
As these leadership capabilities are developed, professional nurses form a decentralized governance structure that accommodates the philosophy, values, and priorities of the nursing staff and articulates with the administrative structure of the broader organization (Jones & Ortiz, 1989; Maas, 1989). The director of nursing champions the evolution of professional nursing practice in the facility and campaigns for the institutional resources needed to make this a reality. While still providing administrative leadership at the level of the institution, the director of nursing also serves as mentor, guide, supporter, and facilitator of the new nursing governance structure in the organization. At the same time, the director of nursing remains accountable for the legally defined functions of the position and establishes or maintains budgetary control over nursing practice expenditures.
Principle 8: Advancing Excellence
Professional nurses advance new visions of excellence for persons living in long-term care through a commitment to research, the expert application of technological innovations and evidence-based practices, and a dedication to social policies that achieve equitable, high quality, and compassionate heath care for all.
Professional nurses believe that Everyday Excellence in nursing homes is a journey rather than a destination. Thus, professional nurses are responsible for advancing excellence in geriatric nursing through a commitment to the cycle of knowledge: discovery, translation, dissemination, implementation, and evaluation (ANA, 2001a). The knowledge process begins with strong programs of nursing and interdisciplinary research in the fields of geriatrics and gerontology (ANA, 2001b). Not every RN will become a researcher, but all professional nurses can and should participate in nursing research, either by involvement in the conduct of research or by alerting scientists to researchable problems in long-term care settings. Professional nurses also must use research evidence to guide clinical nursing practice, make informed choices before adopting technological innovations, and generate wise administrative decisions.
Professional nurses also advance excellence in geriatric nursing by learning to speak some common languages. By introducing computerized information systems into nursing homes, professional nurses can talk about the practice of nursing across places and through time in ways that are meaningful and understandable (Dellefield, 2008a). By joining nation-wide nursing home quality improvement initiatives, professional nurses can learn how different facilities address similar resident care issues and teach people about innovations developed in our own organizations. Through benchmarking clinical outcomes and evaluating the cost-effectiveness of nursing interventions, we contribute to developing a broader healthcare environment in which elder care remains resident-centered, affordable, and of the highest quality. Most importantly, registered nurses consider it a professional obligation to manifest social policies that assure equitable and compassionate health care for persons living in nursing homes, in our communities, our nation, or around the world (ANA, 2003).
Gerontological nurses bring a spirit of caring, theoretical knowledge, clinical skills, and leadership abilities to the nursing care of older persons. However, organizational barriers and social constraints may prevent RNs from incorporating the full spectrum of our professional expertise into solving the resident care challenges presented in nursing homes. The John A. Hartford Foundation Centers of Geriatric Nursing Excellence National Nursing Home Collaborative seeks to improve the quality of care and quality of life of persons living in long-term care facilities by creating opportunities for geriatric nurses to change the structures and processes of elder care in these settings. This paper proposes a framework, Everyday Excellence, for RNs interested in implementing a professional practice model in nursing homes. Professional practice models are an innovative strategy for improving the quality of care in most healthcare settings, including nursing homes. When RNs engage in the everyday process of creating, implementing, and sustaining a professional practice model, they gain a renewed sense of commitment, enthusiasm, and belief in the value of nursing. Registered nurses who practice nursing under such conditions exert more decision-making authority, further develop clinical and administrative leadership skills, and report increased professional autonomy, accountability, and job satisfaction. In response, residents experience an upturn in health-related outcomes, quality of care measures show improvements, and organizations often realize decreased nursing turnover and increased cost-effectiveness. Future research will test the effectiveness of the Everyday Excellence framework in selected long-term care facilities.
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2012 A Nurse I Am Scholarship winners were asked to answer the following:
A. Patients base their perceptions of the healthcare they receive on their experience with the medical personnel they interact with. Describe how two nurses in the film Ã¢â‚¬Å“A Nurse I AmÃ¢â‚¬Â contributed to their patient's satisfaction and well-being by providing an accurate perception of genuine concern, safety, and excellence.
B. How will you ensure that you provide your patients with excellent care and a positive healthcare experience?
Drexel University College of Nursing and Health Professions - Philadelphia, Penn.
Six years ago, I balanced a single spoonful of applesauce in my hand and decided to become a nurse. That spoonful of applesauce was for my father, who lay prone in a hospital bed after suffering from a hemorrhagic stroke. My family, clustered around Dad’s bed, verbally worried about the level of care he was getting now and what he might expect in the future. We learned quickly which nurses took excellent care of my father and which nurses to be wary of. And then one day it occurred to me: the best care my father could get was from me. I could do a better job than some of my father’s nurses—could be more compassionate and respectful towards patients and family members, I could be much more of a calming and informative presence. I took initiative. I picked up the spoon and fed my father. That one simple act launched me on the long, determined journey to become a professional, compassionate, communicative, and spirited nurse.
Today, six years after I decided to become a nurse, I am excited to begin my nursing training at Drexel University. Watching the Cherokee-sponsored “ A Nurse I Am” movie reminded me of my initial resolve following my father’s stroke. I related to and was most inspired by Bob Wilkinson and Ardis Bush, both of whom embody genuine concern, safety and excellence.
Patients and their families can discern genuine concern from their medical professionals. For Bob and Ardis, genuine patient concern comes as naturally as taking a blood pressure or pushing a medication—it is at the core of who they are as nurses. Genuine concern is the hand squeezes that Ardis frequently gives her patients and in the smiles she gives when talking to patients at the bedside. Ardis has the fantastic ability to sit, listen, and provide genuine empathy as is illustrated by her visit with a coworker undergoing treatment for cancer. Bob exhibits this concern when sitting on the bed talking to a young patient about the food she is going to get at Steak and Shake when she goes home. His care is for more than her vital signs at the moment—it is for her mental state also. I am inspired to be like these two excellent role models.
I believe being an excellent nurse also requires a dedication to the safety and wellbeing of our patients. Bob demonstrates that asking questions is a key ingredient to patient safety when he checks the procedure for flushing medication with his team lead before he acts. Communication is also essential to patient safety and Ardis demonstrates this when she asks a patient if he understood what the doctor was saying regarding the initial cause of his pain. She patiently walks the patient through the disease process, seeking to increase his understanding and answer his questions. In addition to their dedication to safety, both nurses embody nursing excellence in numerous ways. To me, excellence is being a nurse who can walk with the patient and family through an illness—either to health and healing, or to a peaceful passing. It is being the RN who comes along side and says to her patients: “I have seen this process before, I have walked others through this, come and let me help you walk through it.” Bob echoes this sentiment when talking about comforting family members: “…they are looking for you to have some kind of comfort, some kind of word of empathy, because they’re going through a great deal of stress, they’re going through the unknown… “ I understand Bob’s thoughts especially well because for the last 2 years I’ve worked as a certified nursing assistant alongside a wonderful team of dedicated staff members at a hospice house. It has been my joy to observe and learn from the hospice nurses and a privilege to walk with patients and families during the last days of life. I have seen firsthand that Bob’s approach—coming alongside patients and their families and treating them as your own—works and provides an atmosphere where excellent nursing takes place every day.
Like Bob and Ardis, I will provide my patients with excellent care and a positive healthcare experience by drawing from my own life experiences. I can still remember the fear and frustration I felt when my father was attended to by nurses whom I could tell did not care. I seek to echo Bob’s sentiments when he stated, “I fight for quality of life every day. I fight for comfort, no pain, no nausea. I fight that my fellow nurses and myself treat each one with dignity as we would want to be treated if we walked in these halls with a sick child or a sick parent.” I will be this kind of RN.