Welcome to the Downstate Magnet ™ Consortium Meeting December 6, 2010

Exemplary Professional Practice (EP)

Exemplary Professional Practice The true essence of a Magnet organization stems from exemplary professional practice within nursing Exemplary professional practice  Is the key driver of a Magnet organization  Requires comprehensive understanding of the role of the professional nurse  Accountability, competence & autonomy

Exemplary Practice Excellence in practice and behaviors worthy of  Honor  Being imitated  Respect and admiration Nurses have control over staffing and scheduling practices Nurses work collaboratively with the other disciplines  As a result, the quality of outcomes is better Nursing practice in Magnet organizations actualizes ideals & beliefs of the profession Nurses are accountable for safe, ethical, evidence-based care

Exemplary Professional Practice Professional practice is based upon tenets  Self-regulating  Peer Review  Control of practice  Code of conduct  Contract with society Nursing theory supports practice Requires values clarification Foundational documents describe principles of nursing

Exemplary Professional Practice Accountability  Ownership for the consequences of one’s decisions and actions  Reflecting on actions and effectiveness  Directs future efforts  Promotes learning (CHCM, 2009, p. 162) Requires ongoing education  Lifelong learning Appreciative Inquiry is a skill set  Identify what is currently working well  What it will take to build on the excellence which already exists  When we are performing at a high level, what components make this possible  Staff should recognize the excellence of co-workers Clarify values  Individual caring, autonomy, sharing, improvement, inquiry  Organizational change, collegiality, consensus, communication, celebration

Exemplary Professional Practice Principles of Practice  Based on standards  ANA Scope & Standards of Practice  ANA Code of Ethics with Interpretive Statements  Nurse Practice Act  Professional organization standards  Other professional standards  Evolving  Evidence-based

Exemplary Professional Practice EP encompasses the following seven forces  Professional Models of Care  Consultation & Resources  Autonomy  Nurses As Teachers  Interdisciplinary Relations  Quality of Care: Ethics, Patient Safety & Quality Infrastructure  Quality Improvement

Empirical Domains of Evidence (EO) Professional Practice Model Safe and Ethical Practice Autonomous Practice Quality Processes

Exemplary Professional Practice Nine subcomponents of EP Professional Practice Model Care Delivery System Staffing, Scheduling & Budgeting Process Interdisciplinary Care Accountability, Competence & Autonomy Ethics, Privacy, Security, & Confidentiality Diversity & Workplace Advocacy Culture of Safety Quality Care Monitoring & Improvement These components work together to create great nursing and outcomes

Exemplary Professional Practice Professional Practice Model  Graphic description which demonstrates relationships & supports decision making  Aligns with the organization’s mission, vision, philosophy and values  Incorporates standards  Provides consistency in practice  Supports nursing care delivery  Centered on the patient

Exemplary Professional Practice Professional Model of Care  Magnet hospitals lead research efforts and test practice models  Nurses analyze data to influence decisions  Engage staff in the budget process  Nurses must know unit based quality data  Measure staff effectiveness against quality outcomes  Discuss skill mix  Could have a good ratio but not have good outcomes  What are the issues?

Exemplary Professional Practice Magnet organizations are expected to outperform the mean of the national database used (benchmarking)  Must submit most recent annual or biannual nurse satisfaction results including the mean or median  Can be displayed at single unit level, like units, or organizational level  Narrative must include participation rates, analysis and evaluation of data and database used  Must follow through on action plans  Information must get back to staff Must demonstrate comprehensive, not cursory, analysis of survey results

Exemplary Professional Practice Care delivery system  Integrated with the professional practice model  Based on acuity, staffing mix, best practices  Is responsive to change  Promotes consistency, efficiency, and accountability for care  Describes  How care is delivered  Skill set required  Nurses’ authority is clear  Authority is the right to act in areas where one is given & accepts responsibility  Varies by unit, population  Roles are clear  Use internal consultants  Productivity is measured

Exemplary Professional Practice All care delivery systems address  Staffing patterns  Schedules  Scope of Practice  Assignments  Accountabilities  Transitions in care  Continuity of care

Exemplary Professional Practice Staffing, Scheduling and Budgeting Processes  Use of trended data to formulate staffing plan  Consistent application of the Care Delivery System  Nurse participation in staffing and scheduling processes  Use of guidelines such as ANA Principles of Nurse Staffing  How nurses analyze data to guide decisions about budget  Formulation  Implementation  Monitoring  Evaluation

Staffing, Scheduling and Budgeting Processes  RN competencies  Management support  Access to clinical experts  Valuing of RN contributions  Commitment to fill vacancies in creative ways Exemplary Professional Practice

Assignments ensure continuity, quality & effectiveness  Good hand off communication (use of tool) Beside nurses should have resources 24/7 Use of consultants (internal/external) enhance care

Exemplary Professional Practice Interdisciplinary Care  Comprehensive plan of care developed through partnerships with  Patients and families  Physicians  Pharmacy  Nutrition  Rehabilitation  Social work  Collegial relationships evident  Mutual respect as everyone’s contributions impact the patient experience and outcomes  Must have conflict management strategies in place  Ensure continuum of care

Exemplary Professional Practice Accountability, Competence & Autonomy  Accountability means being responsible for own actions  Competence– use of communications, technical skills, clinical reasoning, values in daily practice for benefit of individuals and community  Competency assessment contributes to safe and ethical practice  Routine use of self appraisal and goal setting  Peer evaluation means other nurses give fellow nurses feedback during performance appraisals Nurses need to be able to judge performance of peers with similar roles and level of licensure Peer review encourages professionalism through accountability and self-regulation of practice

Exemplary Professional Practice Professional Peer Review  Constructive  Collegial  Systematic  Formalized  At all levels  Conducted over time

 Autonomy  Right to exercise clinical and organizational judgment within an interdependent team in accordance with nursing discipline Control over nursing practice Exemplary Professional Practice

Ethics, Privacy, Security & Confidentiality  How nurses address complex ethical issues  Use ANA Code of Ethics  Make visible  Operationalize principles  Ongoing education  Look for ethical issues in daily rounds  Resolve privacy, security and confidentiality issues

Exemplary Professional Practice Diversity & Workplace Advocacy  Address healthcare disparities  Non-discriminatory climate  Address unsafe, incompetent or unprofessional conduct  Assess community needs  Meet unique needs of patients  Workplace initiatives to address  Caregiver stress  Diversity  Rights  Confidentiality

Exemplary Professional Practice Culture of Safety Proactive assessment & approach  Prevent injuries Innovate Safety initiatives incorporate national best practices Based on standards such as ANA’s Safe Patient Handling and Movement Sufficient resources are available to respond to safety initiatives Facility-wide approach Measure improvements in nurse workplace safety

Nurse sensitive indicators  Submit data for most recent 8 quarters for four nurse-sensitive clinical indicators  Falls and pressure ulcers must be reported  Two other indicators must be chosen Blood stream infection, UTI, VAP, Restraint use, pediatric infiltration or other specialty-specific nationally benchmarked data  Include the median or mean of national database  Can be displayed at single unit level (ICU for example), by clinical groups (Med/Surg units) or at organizational level Exemplary Professional Practice

 Nurse sensitive indicators  Data must be statistically valid; provided by vendor  Majority of data must outperform the mean the majority of the time Five of eight quarters must outperform mean  Narrative must include analysis and evaluation of data Database to which contributed  Must include a graphic display and table with Data from last eight quarters Benchmark mean or median for each quarter Axis labels Clarify if data point is “no data submitted” or “zero” Exemplary Professional Practice

Quality Care Monitoring & Improvement Nurses at all levels analyze data and use national benchmarks Action plans are developed that lead to systematic improvements Resources are allocated for quality  Avoid data paralysis; should be direct, meaningful & simple Magnet hospital data demonstrates outcome measures at or above benchmark mean in patient and nurse sensitive indicators

Quality Care Monitoring & Improvement  Submit data for most recent eight quarters for four measures of patient satisfaction with nursing  Pain  Education  Courtesy and respect from nurses  Careful listening by nurses  Response time  Include mean or median of the database  Data can be display at unit, clinical group (like units), or organizational level  Majority of data must outperform the mean or median the majority of the time Exemplary Professional Practice

Quality Care Monitoring & Improvement  Narrative must include analysis, evaluation and resultant action plans  Other requirements as outlined under nurse sensitive indicators

Exemplary Professional Practice Nine subcomponents of EP Professional Practice Model Care Delivery System Staffing, Scheduling & Budgeting Process Interdisciplinary Care Accountability, Competence & Autonomy Ethics, Privacy, Security, & Confidentiality Diversity & Workplace Advocacy Culture of Safety Quality Care Monitoring & Improvement

Narratives should provide sufficient examples to indicate compliance with the source of evidence (SOE)  Demonstrate not isolated to a single group or area  Must demonstrate attribute exists throughout the organization  Should be straightforward, concise, include minimal extraneous information  Explain clearly how SOE is present and operationalized  Illustrate dynamic/innovative focus on excellence  How integrated and internalized across breadth of organization Exemplary Professional Practice

References American Nurses Credentialing Center (2010). Exemplary Professional Practice: Criteria For Nursing Excellence: Magnet Recognition Program ®. Silver Spring, MD: Author. American Nurses Credentialing Center (2008). Application Manual: Magnet Recognition Program ®. Silver Spring, MD: Author. Creative Healthcare Management (2009). Relationship- Based Care Leadership Practicum. Minneapolis, MN Manual-Updates.aspx