Deborah C. Small, RN, MSN, NE-BC
Robert M. Small, MBA
Like every healthcare system today, the Cleveland Clinic health system is a combination of medical hospitals, institutes, and services in which the implementation of uniform care methodologies faces significant barriers. The guiding principle of the Cleveland Clinic, ‘Patients First,’ focuses on the principle of patient- and family-centered care (PFCC) but deliberately lacks details due to the wide scope of care delivered by the organization. The Stanley Shalom Zielony Institute of Nursing Excellence (the Nursing Institute) at the Cleveland Clinic was charged with standardizing nursing practice across a system with 11,000 registered nurses and 800 advanced practice nurses. The challenge involved providing firm direction on delivering PFCC that was appropriate for all clinical disciplines and could be implemented quickly across existing practices and technologies. Successful implementation required full engagement in the concept of PFCC by what the Institute for Healthcare Improvement has termed the ‘hearts and minds’ of nurses. To achieve these ends, development of a systemwide nursing practice model was initiated. In this article the authors identify the essence of PFCC, consider barriers to PFCC, review their process of developing PFCC, and describe how the Cleveland Clinic health system has implemented a PFCC nursing practice model. In doing so the authors explore how the concept of ‘Passion for Nursing’ was used to stimulate nurse engagement in PFCC.
Citation: Small, D., Small, R., (May 31, 2011) "Patients First! Engaging the Hearts and Minds of Nurses with a Patient-Centered Practice Model" OJIN: The Online Journal of Issues in Nursing Vol. 16, No. 2, Manuscript 2.
Key words: barriers to PFCC, care delivery model, Cleveland Clinic health system, implementation of a model of PFCC, nursing practice model, patient-family-centered care, PFCC, passion for nursing,
Care at the Cleveland Clinic has been always centered on patients. In 1921 the founders of the Cleveland Clinic envisioned a patient-focused environment that delivered “better care of the sick, investigation into their problems, and further education of those who serve.” Over the last 90 years, the Cleveland Clinic Vision (Figure 1) has evolved into ‘best in-class patient experience.’ Patient experience is the measurable outcome of patient- and family-centered care (PFCC) from the patient’s perspective, defined as care that is patient centered, safe, effective, timely, efficient, and equitable (Balik, Conway, Zipperer, & Watson, 2011).
Although today’s Cleveland Clinic health system (CChs), henceforth called the Cleveland Clinic, has a long heritage of being patient focused, it faces the same challenges that other health systems do in implementing PFCC. The Cleveland Clinic, like every healthcare system today, is a complex combination of medical hospitals, institutes, and services where existing technologies and conflicting priorities can create significant barriers to standardizing care quality.
The Stanley Shalom Zielony Institute of Nursing Excellence (the Nursing Institute) is responsible for raising the quality of nursing care at the Cleveland Clinic. It has adopted the motto ‘Delivering on the promise of World Class Care’ in recognition of its mandate. The leadership of the Nursing Institute recognized the need for a systemwide nursing practice model to guide nurses in achieving the Cleveland Clinic vision and demonstrated the commitment of nursing leadership to PFCC. In this article we will identify the essence of PFCC, consider barriers to PFCC, review the process of developing a PFCC-based nursing practice model, and describe how the Cleveland Clinic health system has implemented a nursing practice model of PFCC.
Identifying the Essence of Patient- and Family-Centered Care
...a single, simple description of patient- and family-centered care may not suit the needs of a complex health system. Organizational managers who are trying to implement patient- and family-centered care strategies will quickly face the problem of defining PFCC within their organization, the hardest problem for every organization working to implement PFCC. Since the Institute of Medicine (IOM) identified ‘patient-centered’ care as one of the six keys for quality improvement in health systems in its 2001 report, Crossing the Quality Chasm, there has been a burst of publications trying to clarify what patient-centered care is and how it can be implemented. A search of MEDLINE literature shows 7,103 citations of the term ‘patient-centered care’ of which 5,046 (71%) were published after 2001. A common theme in these publications is the lack of a universal definition (Balik, Conway, Zipperer, & Watson, 2011; Hobbs, 2009; Mead & Bower, 2000).
There is no universal definition of PFCC because the definition changes with the context in which it’s being used. For example, family practice, cancer care, and acute care all have multiple articles with slightly different definitions relevant to their particular research issues. The Institute for Patient- and Family-Centered Care (2010) has published a simple definition that identifies four core concepts, namely respect and dignity, information sharing, participation, and collaboration, as being essential for PFCC.
However, a single, simple description of patient- and family-centered care may not suit the needs of a complex health system. Even the smallest modern health system is a collection of diverse services that can include acute care in urban and rural settings, inpatient care, urgent care, trauma care, home health care, and hospice care. Robinson, Callister, Berry, and Dearing (2008) identified four distinct definitions of patient-centered care depending on one’s focus, specifically: public policy, economics, clinical practice, and patient care. They concluded that regardless of your specific definition, the basic measuring stick of PFCC is the patient’s perception of whether he or she has received patient-centered care.
Nurses play one of the most important roles in influencing patient perceptions. Nurses play one of the most important roles in influencing patient perceptions. After completing a large study of patient ratings of their hospital experiences, Otani (2010) concluded that patient ratings of nursing care have the most direct impact on ratings of overall quality of care and services. In this study Otani evaluated the admission process, nursing care, physician care, staff care, food, and room, and concluded that a bad nursing experience had a disproportionate negative result on quality perceptions. Otani recommended that managers should make as their first priority the elimination of poor nursing practice.
Health systems like the Cleveland Clinic are faced with trying to encourage better patient- and family-centered care while knowing that each decentralized location (and even each unique unit within a location) will have a slightly different view on exactly what PFCC means to their patients. With over 2,000 employed doctors, 11,000 registered nurses (RNs), and more than 800 advanced practice nurses (APNs), plus 30,000 other employees spread over several continents, a restrictive definition of patient- and family-centered care for the entire Cleveland Clinic may prevent some patients from actually receiving PFCC. Hence the Cleveland Clinic has established ‘Patients First’ as a guiding principle designed to communicate the need for patient- and family-centered to every employee. This principle guides the thinking of the managers of the institutes, specialized hospitals, and outpatient facilities which are expected to develop appropriate policies and procedures to handle the unique issues within their facility so that they deliver the world-class care that is the Cleveland Clinic’s reason for being.
Barriers to Successful Implementation of Nursing PFCC
A health system like the Cleveland Clinic faces at least three major barriers when trying to implement uniform PFCC practices. The first barrier is the fact that existing technologies and policies across the system are not uniform; the second is that the model must work for all medical specialties, just as with the definition of PFCC; and the third barrier is getting nurses engaged so they accept and implement PFCC policies that require specific types of personal interaction by individual nurses. Because these barriers are not unique to the Cleveland Clinic, a detailed discussion is provided below.
Non-Uniform Technology and Policies
Although it may be unnecessary to agree on a detailed definition of patient- and family-centered care, health systems do need to implement uniform best practices as quickly as possible if they're going to deliver consistent PFCC. Waiting for existing technologies at the different units of a health system to be standardized can significantly slow down the implementation of consistent PFCC policies. Many health systems have grown through mergers and acquisitions and face the cost and delays of standardizing policies across significantly different technologies. Mergers are common; during the five years ending December 31, 2009, there were at least 278 hospital mergers covering 639 hospitals with 108,711 beds (Irving Levin Associates, Inc., 2010). This represents 11% of the American Hospital Association (AHA) (2010) estimate of 944,277 total staffed hospital beds in the United States (US).
The Cleveland Clinic is a merged system, consisting of 11 hospitals in northeast Ohio, of which 10 were existing hospitals that joined the original Cleveland Clinic hospital through acquisition or joint operating agreements. In addition, there are many offsite care delivery facilities and support operations in northeast Ohio, such as home health and ambulatory surgery centers. There are also hospitals and operations in other states and countries where nursing practice needs to be guided by a nursing practice model.
Cleveland Clinic currently has numerous technologies and policies that are unique to specific areas, most of which are in the process of being standardized. Faster standardization of PFCC requires independence from other standardization projects. Implementation must be done via paper and the Internet, supported by onsite training, ongoing education, and role modeling.
Variety of Medical Specialties and Roles
Nurses perform a variety of roles; yet existing health system practice models are often focused on a single role, namely that of the bedside nurse in a hospital setting. A nursing practice model needs to give guidance that will help nurses perform in a variety of roles, from direct caregiver to central coordinator of care to supporting team member in any of the multiple facilities. Accomplishing this requires clarifying problem-solving processes and knowledge-acquisition strategies while promoting flexibility and the definition of specific practice protocols by the appropriate managers and nurse specialists.
Successful implementation of PFCC requires more than just standardized models, policies, and procedures that tell nurses how to apply their knowledge and skills; it also requires managers to motivate nurses to apply them vigorously. Successful implementation of PFCC requires more than just standardized models, policies, and procedures that tell nurses how to apply their knowledge and skills; it also requires managers to motivate nurses to apply them vigorously. An Institute of Healthcare Improvement Innovation Series white paper by Balik, Conway, Zipperer, and Watson (2011) identified the engagement of the ‘hearts and minds’ of the staff in the shared values of PFCC as one of five key drivers for exceptional PFCC. Another key driver was ‘leadership’ defined as demonstrating that “everything (their emphasis) in the culture is focused on PFCC” (p. 9). This driver is consistent with the Cleveland Clinic vision and guiding principle. The remaining key drivers were respectful partnership, reliable care, and evidence-based care.
The Cleveland Clinic has recognized that nursing engagement is crucial for successful implementation of PFCC and measures this experience with the Gallup Organization’s Employee Engagement Scores (Gallup®, 2011). Nursing engagement has been linked to better patient outcomes. Increases in nursing engagement scores have been shown to have a greater effect on patient outcomes than increases in nurse staffing (measured as the ratio of the number of nurses to total patient days) (Blizzard, 2005).
Development of the Nursing Practice Model
Nurses across the system wanted to have their roles better defined and to be more empowered so as to deliver better care. In 2009, the head of the Nursing Institute, Executive Chief Nursing Officer (ECNO) Sarah Sinclair, established a system-wide organization with four Associate Chief Nursing Officers (ACNOs), respectively responsible for Clinical Practice and Research; Informatics; Clinical Education and Professional Development; and Care Management and Social Work. The organization also includes a Human Resource Business Partner and System Executive/Director of Nursing Operations Integration, both of whom reported to the ECNO. Finally, the chief nursing officers for each of the 11 hospitals report directly to the ECNO. With this structure in place, efforts commenced to standardize nursing across the system.
Initially the ACNO of Clinical Practice, (Deborah Small, first author of this article), conducted a comprehensive review of nursing across the system. This review included a gap analysis, benchmarking of nursing metrics, and interviews with nurses and nurse leaders. Nurses across the system wanted to have their roles better defined and to be more empowered so as to deliver better care. They were eager to participate in the development of a nursing practice model that would define roles and help guide all nursing activity. With an understanding of the current issues with nursing in place, development of a nursing practice model that would define roles and help guide all nursing activity was initiated
The first step in development of the model was the establishment of a steering committee that consisted of key stakeholders representing each hospital and service. An assessment of the existing state of nursing across the system was used to develop ‘guiding principles’ for the model that supported the vision, core values, and guiding principles of the Cleveland Clinic and the Nursing Institute (Figure 1).
Inquiries were made of other hospitals and systems regarding their nursing practice models so as to enhance our knowledge base and establish a common understanding for further development of our model. Physician input was received from the Chair of Patient Safety, the Chair of Regional Quality, and the Chair of the Office of Patient Experience, among others. Staff participation included ten focus groups of nurses from across the system. Participants in these focus groups included Managers, Assistant Managers, Advanced Practice Nurses, Charge Nurses, Registered Nurses, Licensed Practical Nurses, Nurse Aides, and Clinical Instructors. Specific questions addressed what should be included in the model, as well as daily job tasks and barriers to care. Focus group observations and comments were analyzed and summarized as:
- trust and listen to me
- understand the complexity of my work
- define roles and expectations
- simplify my work process
- keep me informed and engaged, and
- do your job and let me do mine.
Next the current nursing care delivery process was mapped out, including accepted definitions, expected competencies, practice environments, and levels of care. Figure 2 presents an example of a chart used to flowchart the care delivery process. Once the assessment was concluded, we identified the following list of issues that needed to be addressed as the model was being developed:
- simplifying our complex processes
- clarifying roles of the caregivers
- providing expert guidance in ongoing care delivery
- promoting continuous learning
- developing meaningful documentation
- integrating technology
- practicing collaboratively
- enhancing continuous communication
- strengthening ongoing innovation
Key Concepts for the Practice Model
The nursing and management literature was reviewed to determine the best theoretical framework for the nursing practice model. It was determined that existing nursing care models, even patient-centered ones, were too specific and task-oriented to adequately encompass the issues facing a complex health system. Rather the model needed to reflect the concerns and needs of the nurse and the Institute as well as the patient. This recognition prompted us to combine nursing care theories with broader-based management theories to achieve complete coverage of identified issues. The work of four theorists, Senge, Greenleaf, Manthey, and Benner, were key to the formation of the model as described below.
Shared vision. One theorist, Senge (2006), in his 1990 book The Fifth Discipline, The Art & Practice of the Learning Organization, provided an understanding of the purpose of the model from a management viewpoint and explained how the model could be used to build a shared vision with staff nurses. Senge described learning organizations as:
...organizations where people continually expand their capacity to create the results they truly desire, where new and expansive patterns of thinking are nurtured, where collective aspiration is set free, and where people are continually learning how to learn together (p. 3).
The primary objective of a nursing practice model needs to be communicating a shared vision that helps nurses manage changes in their practice and maintain their patient focus. The ‘learning organization’ is built on five practices (called component technologies by Senge: systems thinking, personal mastery, mental models, team learning, and building shared vision.) These practices have become common concepts in nursing today. Senge’s work on the learning organization gives significant insight into the operation of a modern health system. While all health systems may appear to be learning organizations, many are being forced to behave in a manner similar to a learning organization because of external influences or events. A rapid evolution in practice, caused by technological growth and abrupt changes due to regulation and payout revisions, has forced modern health systems to react and learn new methods quickly. The main difference between a health system that acts like a learning organization and one that truly is a learning organization is the practice of ‘building a shared vision’ to which many people are truly committed because it reflects their own personal vision (Senge 2006). Without a shared vision the workforce may feel lost and efforts can be unfocused and less effective when exogenous events, i.e. events from the outside, force changes. The primary objective of a nursing practice model needs to be communicating a shared vision that helps nurses manage changes in their practice and maintain their patient focus.
Framework of care. The shared vision of the Cleveland Clinic nursing practice model was based on three concepts, namely serving leader, relationship-based care, and thinking in action. These were combined to form what came to be called the ‘Framework of Care’ for the model. This descriptor was used because these three attributes together support a patient- and family-centered care model. The three concepts are detailed below.
Understanding the serving leader concept helps nurses guide patients in directing their own care. Serving leader. Although almost every nurse acts as a leader in some manner, this role is often hard to understand in a patient-centered environment. Nurses are required to allow patients to direct their own care as much as possible, yet patients and families are unfamiliar with this role and need time and training to accomplish it (Institute for Patient-and Family-Centered Care, 2010). In 1971, Greenleaf introduced the concept of a servant leader which defines this role for the nurses. A serving leader is a leader who is concerned for the growth of the people he is serving (Greenleaf, 1971). Greenleaf’s work and the later development of it by Jennings (Jennings & Stahl-Wert, 2003) comprise a key concept in the Cleveland Clinic Experience, a 16-hour training course that all Cleveland Clinic employees attend. The Cleveland Clinic Experience is a patient-focused program that educates all employees in the concepts of quality, innovation, teamwork, service, integrity, and compassion. Serving leadership is the template that all employees are expected to use in interactions with patients, families, and other employees. The characteristics of the serving leader are: visionary, humility, accountability and drive, leadership, and develops self and others. Understanding the serving leader concept helps nurses guide patients in directing their own care.
Relationship-based care. The most important aspect of developing a practice model for nurses was clarifying and simplifying the role of individual caregivers. This required not only defining the relationship between patients, families, and other team members, but also identifying how the nurse should attempt to deliver care and support. Because neither the term patient- and family-centered care, nor the Cleveland Clinic’s Patients First guiding principle defined the interactive role of the nurse, we drew upon Manthey’s ‘relationship-based care’ (RBC) theory as described by Koloroutis and colleagues (2004) to provide a roadmap of how a nurse could achieve effective patient- and family-centered care. Rather than talking only about the patient-family relationship, RBC presents a picture of the three crucial relationships that care providers must navigate to achieve patient-centered care, namely the care provider’s relationships with (a) patients and families, (b) self, and (c) colleagues (Koloroutis, et al., 2004). This relationship-based role of the nurse in a modern, collaborative environment requires more than the ‘follower’ role of the traditional, paternalistic care model. The serving leader training that every Cleveland Clinic nurse receives prepares them for assuming this role.
Thinking in action. Providing expert guidance in ongoing care delivery was another important requirement. The diverse care needs of the patient population at the Cleveland Clinic meant that the nursing practice model could act as no more than a general guide to care delivery. While Senge’s (2006) ‘system thinking’ (loosely defined as the ability to understand and utilize or change a system) is important, it is not broad enough of a concept to cover everything that a nurse needs to do to deliver optimal patient care. Because much of the thinking that nurses do occurs in emergent situations, Benner’s descriptor ‘thinking in action’ (Benner, Hooper-Kyriakidis, & Stannard, 1999) was used instead of ‘systems thinking’ in our nursing practice model. Benner has described ‘thinking in action’ as ‘thinking linked with actions in ongoing situations’ (p. 2).
Completing the Model with Domains of Nursing Practice
Nurses are frequently reminded of the patient’s expectations of their nurses, namely: ‘Don’t hurt me. Heal me. Be nice to me.’ The Framework of Care was a sound foundation for nursing practice but it did not cover all the things that nurses must know and do to be useful and grow in a rapidly changing environment. The many nursing actions needed to achieve the shared vision and execute the Framework of Care for nursing were summarized into four Domains of Nursing Practice. The term ‘domain’ which means ‘sphere of activity or control’ was used because these are areas that nurses can control and will decide their personal level of participation. While every nurse will participate in every domain to some extent, individual nurses can select their sphere(s) of focus for their particular role and can identify their own goals for professional and personal growth. The four domains consist of practice items with which every nurse is familiar. These domains and their areas of emphasis are described in Figure 3. Each domain is also discussed below.
Quality and patient safety. The first domain, Quality and Patient Safety, is at the forefront of the Cleveland Clinic’s care delivery. Nurses are frequently reminded of the patient’s expectations of their nurses, namely: ‘Don’t hurt me. Heal me. Be nice to me.’ Nurses are the first line of defense in assuring patient safety. Continual emphasis on patient safety is directly rewarded at the Cleveland Clinic as research shows strong improvements with increased professional commitment to patient safety (Teng, 2009).
Both research and experience have shown that care by nurses and other staff members is an important determinant of patients’ evaluation of overall quality of care, willingness to recommend, and willingness to return (Otani, 2010). Nurses at Cleveland Clinic have access to a comprehensive ‘dashboard’ showing these quality measures, an important part of the Clinic’s ongoing commitment to excellent outcomes, data transparency, and public reporting. An example of our dashboard is shown in Figure 4.
Healing environment. More than 150 years ago Florence Nightingale noted the importance of the environment in her book Notes on Nursing (Nightingale, 1860). Today we see a growing body of research that clearly demonstrates the benefits of a healing environment. The current concept of a healing environment has expanded from Nightingale’s primary concern about cleanliness and fresh air to also include concerns about the social, psychological, and spiritual environments (Shaner, 2006). At the Cleveland Clinic, nurses are tasked with maintaining a healing environment that delivers the empathy, care, and compassion that patients and families need to promote healing. To aid nurses in achieving this healing environment, we have developed a list of factors that contribute to a healing environment. This list is presented under ‘Healing Environment’ in Figure 3. It should be noted that this is only a partial listing as a healing environment is in large part a matter of attitude and circumstance.
Research and evidence-based practice. Research and evidence-based practice were combined into one domain as they are integrated and intertwined at the Cleveland Clinic. There is a specific Department of Nursing Research and Innovation reflecting the reality that research is a component that can lead to significant innovation in evidence-based practice (French, 2002). Individual nurses or teams of nurses are responsible for identifying potential practice improvements and developing evidence-based research to validate these potential improvements. The Department of Nursing Research and Innovation helps to guide nurses through the process of conducting research studies and disseminating these findings, along with other best practices. Practice counsels are also used to spread best practices throughout the organization to provide consistent care across the continuum.
Professional development and education. All nurses need continuing education. Additionally there are many opportunities for advanced education that will lead to improved patient care, career advancement, and personal satisfaction. The current movement towards higher educational levels for nurses is evident in the endorsement by organizations such as the American Organization of Nurse Executives (AONE) (Thompson, 2005), and the Institute of Medicine (IOM) (Committee on the Robert Wood Johnson Foundation Initiative on the Future of Nursing, at the Institute of Medicine, 2011) for most nurses to be educated at the baccalaureate level. The Cleveland Clinic nursing leadership is committed to assessing nurses’ competency levels and tailoring their education to their specific learning needs so as to ensure a competent, qualified workforce capable of delivering world class, quality care. Quantifiable data from on-screen simulations and math assessments round out individual nurse profiles and help develop excellence in patient care. Interdisciplinary simulations provided in simulation labs and onsite by the Cleveland Clinic Education Institute give care givers the ability to practice and perfect team work, collaboration, and technical skills.
Once the basic content of the models as described above had been identified, the Cleveland Clinic Marketing and Communications Department, along with an outside marketing and program development expert (the second author of this article) were enlisted to help organize and refine the concepts and aid in developing visual representations, tools, and presentations. The Cleveland Clinic already had in use a number of visual logos, symbols, and themes that the CChs Practice Model Steering Committee wanted to maintain. The process of developing the visual model and other materials was similar to that used to develop a new product at a consumer products company that already had existing brand imagery, logos, and slogans.
Figure 1a: Nursing Institute Image
Existing imagery: Logos and slogans. The Nursing Institute used the Cleveland Clinic Hand Holding a Globe image (Figure 1a) and the theme of ‘Delivering on the promise of World Class Care’ to symbolize the goals of nursing at the Cleveland Clinic. Because the nursing practice model is one of the most important tools in focusing efforts on achieving this promise, it had to reinforce this theme as well as the Cleveland Clinic’s guiding principle of Patients First.
Figure 2a: Nursing Practice Model
Nursing practice model. Centering the Patients First guiding principle in the hand holding globe image was unanimously accepted as a starting point for the practice model imagery. Various layouts and wording were developed, reviewed, and revised to clarify the concept of a shared vision for the four domains of the Framework of Care. The hand became the representation of the shared vision, the Framework of Care was contained in a circle around the globe, and the four domains were the four quadrants of the globe as shown in the model in Figure 2a. A brochure was developed that showed the model along with the detailed elements of each domain (Figure 5.)
Figure 3a: Nursing Colleagues in Care Delivery Model
Colleagues in Care Delivery Model. To help nurses understand how the practice model works in the real world, a visual image of how care would be delivered using the practice model was developed and titled Colleagues in Care Delivery (Figure 3a). This model symbolizes the Cleveland Clinic's shared vision of Patients First by visually centering the RN and care delivery team in the patient. The overlap between the RN and support personnel symbolizes the RN’s role in coordinating care; the overlap between the teams shows the teams that will work most closely together.
Figure 4a: Standard Continuum of Care Pathway [See pdf for full size]
Continuum of Care Pathway. The final piece needed to make the practice model usable in the real world was the development of a tool that would help nurses and nurse managers implement the model. The nursing care delivery process that had been detailed previously (see Figure 2) was simplified into a standard care pathway that included seven major steps in care, along with specific reminders of critical policies (Figure 4a). This care pathway was produced as a ‘Nursing Unit Care Pathway Form’ that could be customized by nurse managers to include the unique needs of their unit (Figure 6). Although this form describes bedside nursing, it can be easily modified to show the continuum of care for any patient-oriented nursing activity.
Other materials. Materials explaining how to present and use the model were also developed. These materials included role summaries, scripts, and PowerPoint presentations. An online tool kit offering vignettes and examples of how to deliver care using scripting and case studies was developed to ensure easy access to all materials.
Implementing the Nursing Practice Model
The term ‘passion for nursing’ was used to summarize the desire to act as a nurse. The completed model and support materials were comprehensive but lacked a ‘hook’ that would encourage world-class performance by engaging the ‘hearts and minds’ of nurses. Such a hook was particularly important in-order-to launch a program requiring active participation because nurses can become actively disengaged or suffer from what is called ‘compassion burnout’ (Douglas, 2011) where they merely go through the motions of delivering care.
The launch materials increased nurse engagement by relating the Nursing Institute’s motto of ‘Delivering on the promise of World Class Care’ back to the reasons people undertake the difficulties, long hours, and extreme stress of a nursing career. The term ‘passion for nursing’ was used to summarize the desire to act as a nurse. ‘Passion for nursing’ is a well-accepted, widely used concept among nurses, with over 155,000 hits (as of this writing) for the exact phrase in a Google search. The Nursing Institute motto was also linked to the implicit promise of care that nurses make to their patients every day. This promise to patients has been illustrated through a Cleveland Clinic program called ‘The Patient Experience’ which is summarized by the theme of ‘Cleveland Clinic patients assume world-class care but they experience empathetic care.’ Both of these themes were supported by real-life stories of managers and patients.
The program was launched to 500 Cleveland Clinic Nurse Managers at the annual leadership retreat on October 5, 2010, as the ‘Colleagues in Care Nursing Practice Model’ using a PowerPoint presentation that focused nurses on feeding their passion for nursing through implementation of the model.
The importance of the nursing practice model for the continued improvement of patient- and family-centered care at the Cleveland Clinic can be summarized as follows:
- Nurses are the biggest factor in getting patients to feel that they have received patient- and family-centered care.
- Patients understand and respond positively when nurses are engaged, understand their role, and are passionate about their career.
- The nursing practice model and its supporting materials give a unified approach to nursing at the Cleveland Clinic and help nurses feel like they are part of a unified team delivering the world's best care.
- An important part of the Nursing Institute’s efforts is to allow all nurses to fulfill their passion for nursing.
As of this writing, the model is in the process of being rolled out to all 11,000 RNs and 800 APN’s in the Cleveland Clinic using a proprietary toolkit; online educational modules; and onsite presentations given by CNOs, supported by videos of nurses using model concepts. The main focus of the rollout program consists of mandatory training sessions for every nurse and the assignment of champions to role model execution of the model.
The Nursing Institute will be tracking the success of the model over time. This success will be measured by tracking improvements in Hospital Consumer Assessment of Healthcare Providers and System (HCAHPS) scores of patient’s perceptions of care.
Deborah C. Small, RN, MSN, NE-BC
Ms. Small is the Chief Nursing Officer for Cleveland Clinic health system (CChs), Fairview and Lakewood Hospitals. She has also served as the Associate Chief Nursing Officer for Clinical Practice and Research for the Cleveland Clinic health system. She has over 30 years of experience as a bedside nurse, nurse educator, and nurse executive. Deborah received her BSN from the University of North Carolina at Greensboro and her MSN from Duquesne University, Pittsburgh, PA.
Robert M. Small, MBA
Mr. Small contributed his marketing and program design expertise in developing the CChs Nursing Practice Model and the related support materials. He has over 30 years of experience in marketing and strategic planning as a brand manager and marketing executive, and is an expert in the design and use of customer surveys. Robert received his BA in economics from the University of North Carolina at Charlotte and his MBA from Columbia University, New York, NY.
Agency for Healthcare Research and Quality. (2011, March 20). CAHPS®: Surveys and tools to advance patient-centered care. Retrieved April 1, 2011, from https://www.cahps.ahrq.gov/default.asp
American Hospital Association. (2010, December 6). Fast facts on US hospitals. Retrieved April 1, 2011, from www.aha.org/aha/resource-center/Statistics-and-Studies/fast-facts.html
Balik, B., Conway, J., Zipperer, L., & Watson, J. (2011). Achieving an exceptional patient and family experience of inpatient hospital care. Retrieved March 9, 2011, from IHI.org: www.ihi.org/IHI/Results/WhitePapers/AchievingExceptionalPatientFamilyExperienceHospitalCareWhitePaper.htm
Blizzard, R. (2005, December 27). Nurse engagement key to reducing medical errors. Retrieved March 2011, from Gallup: www.gallup.com/poll/20629/Nurse-Engagement-Key-Reducing-Medical-Errors.aspx
Benner, P., Hooper-Kyriakidis, P. L., & Stannard, D. (1999). Clinical wisdom and interventions in critical care: A thinking-in-action approach. W.B. Saunders Company.
Committee on the Robert Wood Johnson Foundation Initiative on the Future of Nursing, at the Institute of Medicine. (2011). The future of nursing: Leading change, advancing health. Washington, DC: The National Academies Press.
Douglas, K. (2011, February). When caring stops, staffing doesn't really matter. Nursing Economics, 28(6), 415-419.
French, P. (2002). What is the evidence on evidence-based nursing? An epistemological concern. Journal Of Advanced Nursing, 37(3), 250-257.
Gallup®. (2011). Employee engagement. Retrieved April 1, 2011, from www.gallup.com/consulting/52/Employee-Engagement.aspx
Greenleaf, R. K. (1971). The servant as leader. Journal of Current Social Issues, 9(5), 4-29.
Hobbs, J. L. (2009). A dimensional analysis of patient-centered care. Nursing Research, 58(1), 52-62.
Institute for Patient-and Family-Centered Care. (2010). FAQs. Retrieved November 24, 2010, from Institute for Patient-and Family-Centered Care: www.ipfcc.org/faq.html
Irving Levin Associates, Inc. (2010). The hospital M & A market: Five-year review & outlook, 2010. Norwalk, CT: Irving Levin Associates, Inc.
Jennings, K., & Stahl-Wert, J. (2003). The serving leader: 5 powerful actions that will transform your team, your business, and your community. San Francisco: Berrett-Koehler Publishers, Inc.
Koloroutis, M., Manthey, M., Felgen, J., Person, C., Kinnaird, L., Wright, D., et al. (2004). Relationship-based care: A model for transforming practice. (M. Koloroutis, Ed.) Minneapolis, MN: Creative Healthcare Management, Inc.
Mead, N., & Bower, P. (2000). Patient-centeredness: A conceptual framework and review of the empirical literature. Social Science & Medicine, 51(7), 1087-1110.
Nightingale, F. (1860). Notes on nursing. (Harrison and Sons) Retrieved April 1, 2011, from Project Gutenberg: www.gutenberg.org/files/17366/17366-h/17366-h.htm
Otani, K. W. (2010). How patient reactions to hospital care attributes affect the evaluation of overall quality of care, willingness to recommend, and willingness to return. Journal Of Healthcare Management / American College Of Healthcare Executives, 55(1), 25-37.
Robinson, J. H., Callister, L. C., Berry, J. A., & Dearing, K. (2008). Patient-centered care and adherence: Definitions and applications to improve outcomes. Journal of the American Academy of Nurse Practitioners, 20(12), 600-607.
Senge, P. M. (2006). The fifth discipline, the art & practice of the learning organization. New York: Doubleday.
Shaner, H. (2006). Nightingale knew more than she thought - Environment as a phenomenon in nursing: Reflections from nurse theorists. Retrieved November 23, 2010, from The Nightingale Institute for Health & the Environment: www.nihe.org/enviropn.html
Thompson, P. (2005). Tomorrow's nurse. We all have a stake in the redefinition of nursing's role and education requirements. Hospitals & Health Networks / AHA, 79(6), 106.
Figure 1. Nurse Practice and Patient Care Principles for the Practice Model
Cleveland Clinic Vision: To provide best in-class patient experience, superior clinical outcomes, and excellence in research and education
CChs Guiding Principle: Patients First
Nursing Vision: Delivering on the promise of World Class Care
Nursing Institute Goals:
- To be a leader in world class care
- To create nursing practice and care delivery models that will be understood and applied globally
- To provide nursing care that exceeds all others
Core Nursing Values:
- Critical thinking
Optimal patient outcomes are based on:
- Ensuring patient safety and quality
- Providing consistent, evidence-based nursing practices based on the nursing process, critical thinking, and role optimization
- Fostering a healing environment that is patient- and family-centered, culturally sensitive, compassionate, service-oriented, and that utilizes interdisciplinary collaboration
- Expecting professionals to be competent, accountable, fiscally responsible, and ethical
- Leveraging technology to support nursing practice and increase time with patients
- Maintaining regulatory and practice compliance
- Supporting lifelong learning and teaching.
Figure 2. Nursing Care Delivery - [See pdf for full size]
Figure 3. Nursing Practice Model Domains
AREAS OF EMPHASIS
Quality and Patient Safety
- National quality indicators
- Performance improvement
- Safe clinical care supported by appropriate staffing
- Skilled communication and handoff across the continuum of care
- Change management
- Safe staffing
- Fiscal responsibility
- Ongoing measures
- Empathetic, respectful, compassionate, and holistic care
- Effective communication and relationship management<
- Patient- and family-centered care
- Shared effective decision making
- Interdisciplinary collaboration
- Diversity embraced
- Technology leveraged to support practice
- Culturally sensitive care
- Positive Patient experience
Research & Evidence-Based Practice
- Evidence-based clinical practice and management
- Utilization of Nursing Knowledge
- Clinical Inquiry
- Integrated technology
- Use of the nursing process in care delivery
Professional Development & Education
- Successful on-boarding
- Clinical Ladder
- Leadership skills
- Shared Governance
- Academic partnerships
- Elevated professional image of nursing
- Involvement in professional organizations and communities
- Life-long learning
Figure 4: Nursing Dashboard - [See pdf for full size]
Figure 5: Nursing Practice Model Brochure-Interior - [See pdf for full size]
Figure 6: Care Pathway Form Example - [See pdf for full size]
© 2011 OJIN: The Online Journal of Issues in Nursing
Article published May 31, 2011
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