One hallmark of a profession is to demonstrate a unique body of knowledge. The impetus of that knowledge may be in the form of a nursing framework or model, or theory. A conceptual framework (synonymous with model) is defined as a set of concepts and those assumptions that integrate them into a meaningful configuration.1 More concrete than a framework, a theory is a set of interrelated concepts, definitions, and propositions that presents a systematic view of phenomena by specifying those relationships.1 Furthermore, the incorporation of a nursing practice framework in a healthcare setting demonstrates that the organization embraces nursing as a profession and facilitates professional development as well as meeting requirements set forth by the American Nurses Credentialing Center' (ANCC's) Magnet Recognition Program(R).2
To meet this Magnet Recognition program requirement, many organizations choose from existing nursing theories and implement professional nursing practice through a single theory. The expectation is set that the theory be adopted across all nursing units, regardless of the type of patients or nursing practice. Because theories are more concrete than frameworks, nursing theories focus on an aspect of nursing practice and have a specific underlying context. All nursing theories explain some portion of phenomena in nursing, such as Jean Watson and her Theory of Human Caring,3 where her focus is on caring; Dorthea Orem's focus is on self-care4; and Madeline Leininger focuses on transcultural nursing.5 The problem with the adoption and implementation of a single nursing theory is that no 1 theory can apply to all aspects of nursing practice. Because theory use is dependent on one's worldview,5 "rigid application and preservation of nursing theories understandably have chilled nurses' appreciation for theories' role in practice."6(p426) This article will review the successful incorporation of a nursing practice framework that facilitated both meeting the Magnet(R) standard and creating a foundation where all nursing theories can be incorporated.
Banner Health is a private not-for-profit healthcare system in the western United States located in 7 states, including 23 hospitals and medical centers, home care, hospice, outpatient surgical centers, medical offices, and long-term care facilities. Of the 23 facilities, 9 are critical-access hospitals. The original intent of Banner Health was to seek Magnet recognition for the Arizona region, a total of 10 hospitals, through the process of system designation. With a system designation, the organization needed to assess what components were needed at the system level to achieve success. One critical component was the adoption of a professional practice framework. Although some Banner Health facilities had chosen a nursing theorist, there had been issues with the adoption and incorporation of theory into practice. Based on system Magnet eligibility requirements, sources of evidence required standardization in many elements across all facilities such as the same performance improvement methodology, peer review, and performance appraisals. Nursing leadership believed that to create standardization, a single practice framework, as opposed to a nursing theory, was needed to bring together all the elements of nursing practice in the system.
The corporate-level clinical delivery department initiated and supervised the work of creating the practice framework. This department consisted of RNs prepared at the master's and doctoral level who reported to the vice president (VP) of clinical services. For the purposes of the Magnet document, the VP of clinical services was considered the system chief nursing officer (CNO) and led the framework development team of system (corporate)- and facility-level RNs. The first step was to create a straw model that would be the rough draft used to initiate discussion with the nursing stakeholders in Banner Health.
A set of guiding principles was discussed before drafting the straw model during this development stage, which included that the framework should demonstrate a dynamic nonlinear state, be evidence based, and build on existing standards in the healthcare community. Foundationally, because nursing at Banner Health is defined based on the American Nurses Association (ANA)7(p6) Social Policy Statement as "the protection, promotion, and optimization of health and abilities, prevention of illness and injury, alleviation of suffering through the diagnosis and treatment of human response, and advocacy in the care of individuals, families, communities, and populations," the incorporation of the ANA standards was a given. In developing the rough draft, 4 assumptions were also made. The first assumption is that the Banner nurse's primary focus is the patient, which includes the patient's family and community. The next 3 assumptions supported that accountability, communication, and innovation become embedded in the framework.
These assumptions and guiding principles led to the initial development of a circular model that incorporated both the ANA Scope and Standards of Nursing Practice8 and the Institute of Medicine (IOM) Dimensions of Quality.9 The ANA document was important for incorporation into the framework because the ANA is the overarching professional organization for all RNs regardless of practice and maintains the code of ethics for nurses,10 as well as a definition of nursing.11(p7) The ANA has also endorsed the IOM's Dimensions of Quality, which reinforce nursing's commitment to quality patient care. Quality is the driving force for nursing and the organization.2 Many Banner Health documents used concepts from these documents already; therefore, inclusion of these concepts seemed appropriate in developing this framework.
Once the rough draft was developed, stakeholders were identified for inclusion in the preliminary feedback stage. The CNOs felt that it was important that all nurses, regardless of background or experience, should be able to identify with the model to fully integrate the model in and across all units and facilities. Stakeholders were chosen by facility leaders and included novice nurses, experienced nurses, educators, advanced practice RNs, nursing leaders, as well as the CNOs from the various facilities. The rough draft was taken to each group, and after an explanation of the intent for the model was given, feedback was elicited from each group of stakeholders. The framework development team reviewed all feedback and made changes as consistent with the aforementioned guiding principles and assumptions. Meetings were held with all the stakeholders to discuss changes were and were not made and to elicit feedback. After reaching saturation with comments and feedback, the final copy, now a framework, was presented to all the facility CNOs, along with a position paper describing the need, the development process, and proposed integration process. The framework and position paper were approved by all the facility CNOs.
Posters were developed and posted on all hospital units, and an education learning module was developed to teach all RNs about the framework. This entire development process lasted 18 months. Once the framework was developed, it was incorporated into other important areas required for system Magnet elements, including RN job descriptions, clinical expert model, yearly nursing awards, peer review, education, orientation, and research- and evidence-based practice projects.
The final version of the framework is called the Professional Nursing Practice and Development Framework (PNPDF). Since the original development of the first version, the ANA has updated the Scope and Standards of Practice,11 and therefore, the Banner version was updated to reflect these changes (Figure 1). It consists of 3 interconnected circles around the patient. Hash marks, not solid lines, make up the boundaries of each circle to demonstrate the fluidity of all the concepts. These 3 circles were named Contribution to the Patient, Contribution to the Profession, and Contribution to Society and correspondingly refer to the ANA scope of professional practice, ANA scope of professional performance, and the IOM dimensions of quality.
|Figure 1. Framework for professional nursing practice and development.|
Contribution to the Patient
Closest to the patient-centric circle is what is also known as the ANA Standards of Practice,11 which demonstrate the critical thinking model known as the nursing process. The nursing process is how the nurse should be organizing and thinking about the daily care of the patient. Because nurses have become more task oriented and physician order driven, the decision was made by the framework development team to highlight the nursing process as an integral contributor to excellent patient care. "The nursing process encompasses all significant actions taken by registered nurses and forms the foundation of the nurse's decision-making."8(p4) This is the nurse's direct contribution to the patient.
Contribution to the Profession
The next circle represents the ANA Standards of Professional Performance and describes the level of expected behavior in the professional role.8 The framework development team felt strongly that professional nurses affect and influence healthcare through professional performance. Research demonstrates that professional development is an important domain for a Magnet work environment.2 This circle also represents the investment that nurses place in themselves and their contribution back to the nursing profession.
Contribution to Society
The IOM has published 6 dimensions of quality, which include safe, timely, efficient, effective, equitable, and patient-centered care. The impact made by nurses on the dimensions of quality demonstrates nurse's integral role in our healthcare system. The dimensions of quality are noted in the outer and innermost circles. Excellent Patient Care was placed in the middle of our framework, which reflects the sixth IOM dimension of quality, Patient-Centered Care. The patient is placed in the center of our framework based on the Code of Ethics for Nursing, which states, "the nurse's primary commitment is the patient, whether an individual, family, group, or community."10(p9) Although nursing focuses on the outcomes of the patient in the center of our framework, our responsibility to quality and safety extends to the entire community. The ANCC2(p56) expects that organizations maintain a strong community presence and is seen as a productive corporate citizen. This is our contribution to society.
The Framework in Action
As the region was moving toward system Magnet designation, 1 facility was preparing for redesignation. To ensure no lapse in its Magnet designation, this facility was going to move forward with individual redesignation while the system prepared for future system designation. Banner Good Samaritan Medical Center adopted and rolled out the education faster than other facilities. The incorporation of the framework contributed to the successful redesignation of the facility in 2010. In a Magnet exemplar (Figure 2), the framework (Figure 3) was used to illustrate the application and modification of the framework in the practice setting (Figure 2).
|Figure 2. Exemplar used to illustrate the application and modification of the framework in practice.|
|Figure 3. Exemplary professional practice. Utilizing the professional practice framework to care for an oncology patient. Version 1 was used in this depiction using the previous (2003) version of the American Nurses Association Scope and Standards of Practice.|
During the development and incorporation of the model, restructuring occurred at Banner Health, which changed the goal of seeking Magnet designation as a system. However, the facility CNOs and nurses felt strongly about the success and need for the standardized framework and have continued to incorporate and use it to guide their professional nursing and individual Magnet journeys. It is the expectation of the Banner Health system leaders that the individual facilities continue forward in their Magnet journeys.
In addition, several changes were made to the ANA Scopes and Standards of Practice and Professional Performance in 2010, and the model has been updated to reflect uniformity with the professional organization as approved by the system CNOs and, for the first time, the system Professional Nursing Congress. The Professional Nursing Congress is a systemwide nursing shared leadership council developed after the original framework was developed. The revisions to the framework made it necessary to reprint the framework posters to repost on all units, as well as necessary revisions of any supporting documents or education were completed to remain in line with the new framework version.
"The mindful use of theory separates the technical from the professional worker."12(p427) The PNPDF was created to provide a structure for nurses that describes various evidenced-based concepts that are necessary to support and develop professional nursing practice and promote excellent patient care experiences. This framework enhances the nurse's understanding of expectations as a professional regardless of his/her practice setting and serves as a guide for strategic planning, program development, and clinical practice for nursing at Banner Health.