Differentiated Nursing Practice: A Proposed Model For Perioperative Practice

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Differentiated Nursing Practice A PROPOSED MODEL FOR PERIOPERATIVE PRACTICE

Janet A. Lewis, RN ifferentiated nursing practice, a system of patient care delivery based on varying levels of nursing competencies, is not new to the nursing world. On an informal basis. nursing managers always have differentiated between nurses, based on demonstrated c o m p e t e n c e . when p l a n n i n g patient c a r e assignments. I Recently. however. many nurses have attempted to design formal differentiated practice models. This trend has resulted from the evolution of a variety of nursing education programs (ie, associate degree, diploma. baccalaureate, graduate degree, nursing doctorate) and their associated outcome competencies.' AORN's Project 2000 Team to Identify New Practice Models for Perioperative Nursing proposes differentiated practice as a nursing care delivery model for perioperative nurses. This is the second in a series of articles on nursing practice models written by members of this

Project Team. Future articles will present other models of care delivery and will include suggestions and implications for their use in the perioperative environment.

Defining Differentiated Practice

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he American Academy of Nursing has defined differentiated practice as integrated care: A system of' patient care delivery that integi-Utes the allocation of i'esources (human and material) over a variety cf settings MYthin un appivpriate time fi-ame and through the diflerentiation of nursing prwtice. Diferentiation implies expansion of patient (uri) management beyond physiologic stabilization to the entire episode of illness fi-on?pi-e-admission to post-dirchurge.'r

o f surgical services at Riverside Regional Medical C e n t e r , NeMlport N e w s , V a . She eur-ned h e r diploma in nursing f r o m S t Luke's Hospital School o f Nursing, Kansas City, M o . her bachelor of science degree in n u rs i n ,g f I' o m North west Miss o u r i State Uniwrsity, Muryville, and her master of arts d r g r e e i n u dm i n i s t r-at i e sc i e n ce ,from George Washington Uniizersity, Washington, DC. She is a member of the AORN Project Teom to Identqy New Practice Models f o r Pei-ioperutii.e Nursing. 17

Janet A. Lewis, RN. M A . CNOR, is the director

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History of Differentiated Practice

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ifferentiated practice emerged during World War I1 when the nursing shortage created the assistive roles of practical nurse and nursing assistant.J The need to match the practice role with educational preparation subsequently received much attention over the ensuing decades. In 1965, the American Nurses Association’s first position paper on nursing education described two levels of education and practice: a baccalaureate for professional nursing practice and an associate degree for technical nursing p r a ~ t i c e . ~ In 1989, the National Commission on Nursing Implementation Project summarized the status of differentiated nursing practice in this statement: IFI order to improve patient care, effectively utilize health care resources, and create a more satisbing work environment, roles and functions of nursing personnel should he based on education, e.t-perience, and competence, and nurses should he compensated accordingly. The American Academy of Nursing has promoted differentiated practice as being effective in enhancing RN job satisfaction, increasing recruitment and retention rates, and improving productivity .’ Tim Porter-O’Grady, RN, EdD, CS, CNAA, FAAN. believes that the practice of nursing must be differentiated and that a differentiated practice model will position nurses as esteemed professional business partners, both within the profession and beyond. Differentiated practice roles, Dr Porter-O’Grady maintains, can help create a nursing care delivery system that is based on client needs. Dr Porter-O’Grady cites three recent developments that justify differentiation of nursing practice roles: Fragmentation of client care as a result of increasing physician subspecialization and the emergence of a decentralized, distributive health care delivery system; Changing career expectations of graduates who seek career advancement 684

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opportunities based on education and competence; and Changing reimbursement options that demand coordinated care, thus eliminating redundancy and gaps in services.* Despite nearly 30 years of rhetoric, to date, no clear role distinction has been made between bachelor of science in nursing (BSN), associate degree (ADN), and diploma nurses in most practice settings. Other than serving as a component of some clinical ladders, the educational preparation of most nurses is not differentiated in the basic RN job position description; most positions are advertised as being specific only to the type of practice setting (eg, orthopedics). New nursing practice models that define differentiated practice roles are needed.

DifSerentiated Practice Models Studied ‘urses have designed and participated in a number of pilot projects to evaluate differentiated nursing practice. A few of these projects are highlighted here. South Dakota. In 1978, the South Dakota State Nurses Association adopted a resolution consistent with the American Nurses Association’s position on two levels for entry into nursing practice. Six years later, the South Dakota Board of Nursing called for a statewide plan for nursing education that would meet the needs of the state’s health care consumers and clarify the future of nursing practice and education in the ~ t a t e . ~ The South Dakota plan incorporated concepts and models developed by the Midwestern Alliance in Nursing (MAIN), which had identified differentiated competencies of ADN and BSN graduates and used them to develop specific curricula, position descriptions, and orientation programs. The MAIN project established parameters for ADN and BSN role performance with ADN nurses providing direct patient care to individual clients and BSN nurse s directing care to individuals, families, groups, aggregates, and communities. Figure 1 illustrates the MAIN differentiated practice role

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Fig 1. Differentiated practice role of nurse. (Adapted from the Journal of Professional Nursing 3 (JulyiAugust 1987),P Primm, with permission from W B Saunders Co, Orlando, Fla)

for nurses.’” Figure 2 illustrates the interface of role components in nursing practice roles as proposed by the MAIN project. There are three basic components of the practice role: provision of patient care, communication to and on behalf of the patient, and management of patient care. Integration of care occurs as these components interface with each other. Teaching, coordination, and delegation are activities that

evolve through this process.” One of the pilot sites for the South Dakota project was the Sioux Valley Hospital, Sioux Falls, SD. Nurses at this hospital implemented differentiated practice on five demonstration units. The R N s were “factored” into two roles-case associate or case manager. The case associate role was the traditional staff role, and the case manager role included management, delegation, and greater interdepartmental and interagency coordination. 685

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Member of Profession Accountable Self-Directed

Communication Technical Skills

Management of Care

Method of Practice

Fig 2 . Practice role of nurse: interface of role components. (Adaptedfrom the Journal of Professional Nursing 3 (JulylAugust 1987),P Primm, with permission,from W B Sounders Co, Orlando, Fla) Of the 187 nurses participating, 85 were assigned to the case manager role, and 102 were designated as case associates. Nurses with BSN, diploma, and ADN preparation were represented in each group. The nurses expressed mixed feelings about the project and the coexistence of two distinctly different practice roles. Although the case associate nurses enjoyed traditional nursing practice, some felt they “lost” something because another level of function was practicing alongside. No nurse, 686

however, left because of the project.12 The differentiation of nursing practice in the Sioux Valley project led to a nursing case management model. Similar practice models have been implemented, and various approaches (eg, case management, career ladders) have based the differentiation of roles on the levels of educational preparation of the nurses. New Jersey. The New Jersey State Nurses Association task force wanted to differentiate the competencies of the associate nurse and the

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LPN

Degrees

1 -ct

Stages I-IV

U

Roles: Member of th profession Provider Teacher Advocate Manager

Fig 3. Colorado Differentiated Nursing Practice Model. (Adapted with permission fi-om the Colorado Differentiated Nursing Practice Model, I992 Colorado Nui-sing Tri-Council Tusk Force, Denver) professional nurse. The task force developed a competency model, incorporating practice standards and practice settings and made the model practice based. In response to the dilemma of numerous practice settings, the task force incorporated the terms distributive and episodic into the model with the belief that these terms provided sufficient flexibility to include all nursing practice settings.I3 Colorado. The state of Colorado authorized a task force to develop a nursing practice model that defined the competencies and roles for the various nursing education programs in the state. The resulting Colorado Differentiated

Nursing Practice Model (Fig 3 ) used entrylevel competency statements and role descriptions for each of the various levels of nursing educational programs. Competency statements for each educational level were developed to define performance, with competency being demonstrated through performance that integrates cognitive, psychomotor, and affective skills in nursing practice.I4 The Colorado Nursing Tri-Council Task Force identified the need to expand the entrylevel competencies to include increased professional growth and development of a nurse. Competencies were incorporated into five 687

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Table 1

Career Stages’ Stage 1

The stage at entry from a nursing program.

Stage 2

The stage characterized by the nurse who competently demonstrates acceptable performance by using the nursing process effectively, adapting to time and resource constraints.

Stage 3

The stage characterized by the nurse who is proficient and able to identify a situation as a whole by recognizing relationships between policy and outcomes; mentoring individuals to recognize their potential; facilitating change by using interdisciplinary expertise: and seeking professional growth.

Stage 4

The stage characterized by an expert nurse with in-depth experience who provides high-quality care in a specialized area using intuitive skills, modern technology, and professional collaboration. This individual provides innovative solutions to problems, consultation to others, and expertise to advisory boards in nursing and related fields.

Note 1. Coiorddo Nursing Tri-Council Task Force, The Colorado Differentiated Nursing Practice Model (Denver: Colorado Nursing Tri-Council Task Force, 1992) 6.

defined nursing roles: member of the profession, provider, teacher, advocate, and manager. I n addition, four career stages were defined (Table 1).

Adrwitages ifferentiated nursing practice can provide the opportunity for perioperative nurses to engage in the total scope of patient care. Differentiated practice demonstration projects have documented increased satisfaction f o r nurses through decreased turnover, mobility between roles, the opportunity to have more involvement in the progress of patients’ care, and overall improved qualit y of nursing care.” Increased patient and family satisfaction and cost-effective delivery of patient care and resource utilization also 688

have been noted in these projects.lh

Disadvantages

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he most prevailing disadvantage of differentiated nursing practice comes from within the world of nursing. The emotional factors associated with defining nursing practice by levels probably are the most difficult issue to overcome. Nurses who participated in the various pilot projects exhibited fear of the relative value placed on each role, fear about how nurses would be chosen for patient care, and resentment over the splitting of responsibilities for patient care.” Disadvantages are inherent in any change process. Implementing a differentiated nursing practice model requires education, considera b l e p l a n n i n g , a n d i n p u t by t h e p e o p l e

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involved. The educational process must be incorporated from inception through implementation. Following implementation, education must be ongoing to reinforce the concepts of differentiated nursing practice. The move to differentiated nursing practice must be accepted and supported by members of the nursing profession. The world of nursing has been divided in many ways for many years; differentiated nursing practice could be viewed as another divisive factor.

Diferentiuted Periopei*utiwNursing Pruactic‘e

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erioperative nursing can adapt the patterns established in various differentiated nursing practice projects. A form of differentiated nursing practice already exists in AORN’s position statement on the necessity for the registered nurse in the operating room.lX This position is underscored by the Joint Commission on the Accreditation of Healthcare Organizations’ standard, which specifies that a qualified registered nurse must supervise patient care provided in the operating room.’” If differentiated nursing practice were implemented in p e r i o p e r a t i v e settings, a team approach could incorporate ADN, diploma, and BSN nurses. As the primary nurse within the operating room. the ADN or diploma nurse could communicate the plan of care to the other surgical team members. and the surgical team could receive feedback on the outcome of care. In this model. the BSN nurse would be responsible for communicating with multiple surgical teams. The BSN perioperative nurse might function as the service or specialty nurse with a broader scope of responsibilities to both the patient and members of the surgical team. The development of preadmission assessment centen has paved the path for the perioperative BSN nurse to participate and manage the entire scope of care for the surgical patient. This involvement with the patient and the patient‘s family or significant other throughout all the activities surrounding hospital admission (eg, preoperative teaching, discharge preparation, 690

follow-up home care to assess quality outcomes of perioperative care) offers a new and exciting scope for the nurse who is prepared to move outside the confining walls of the operating room.

Conclusion

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or more than 25 years, the issue of entrylevel education f o r nursing has been debated. Considering differentiated nursing practice, the issue of entry into practice has been said to be meaningless when focused only on educational preparation.*” It is essential to identify the practice setting to be able to clarify the various roles and their associated competencies. This is pertinent for perioperative nursing today with the wide variety of settings in which intraoperative procedures are being performed. Differentiated nursing practice has received so much attention in the nursing world that in 1990, an entire conference was devoted to presentations on the subject.2’ Various practice settings have implemented differentiated nursing practice, often coupling this innovation with the addition of case management. Differentiated practice is relevant to today’s health care environment. It can be a major factor in moving nursing to meet the challenges of the twentyfirst century. 0 Notes 1 . M L McClure, “Differentiated nursing practice: Concepts and considerations,” Nursing Outlook 39 (May/June 1991 ) 3, 106. 2. P Primm, “Differentiated nursing case manage m e n t and differ en t i a t e d nursing practice ,’’ Journal qf Professional Nursing 3 (July/August 1987) 218-225. 3. American Academy of Nursing, Diflerentiat-

ing Nursing Practice into the Twenty-First Century, ed I Goertzen (Kansas City, Mo: American Academy of Nursing, 1991) 9% 4. McClure, “Differentiated nursing practice: Concepts and considerations,” 3, 106. 5 . American Nurses Association Committee on Education, “American Nurses Association’s first position on education for nursing,” American Jortrnul of Nursing 65 (December 1965) 106-1 1 1. 6. American Organization of Nurse Executives,

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Current Issues and Perspectives on Differentiated Practice (Chicago: American Hospital Association, 1990) 69. 7. American Academy of Nursing, Dijferentiating Nursing Practice into the Twenty-First Century, 98. 8. T Porter-O’Grady, Implementing Shared Governance (St Louis: Mosby-YearBook, Inc, 1992) 178. 9. J Koerner, “Implementing differentiated practice: The Sioux Valley Hospital experience,” Journal of Nursing Administration 19 (February 1989) 13-20. 10. Primm, “Differentiated nursing case management and differentiated nursing practice,” 220. ll.Ihid,221. 12. Koerner, “Implementing differentiated practice: The Sioux Valley Hospital experience,” 13-20. 13. American Academy of Nursing, Differentiating Nursing Practice into the Twenty-First Century, 224. 14. Colorado Nursing Tri-Council Task Force, The Colorado Differentiated Nursing Practice Model (Denver: Colorado Nursing Tri-Council Task Force, 1992) 6. 15. American Academy of Nursing, Differentiating Nursing Practice into the Twenty-First Century, 61-71; K Malloch, D Milton, M Jobes, “A model for differentiated practice,” Journal of Nursing Administration 20 (February 1990) 2, 2026; Koemer, “Implementing differentiated practice: The Sioux Valley Hospital experience,” 2, 13-20; G A Harkness, J Miller, N Hill, “Differentiated practic e : A three - d i m en s i on a 1 mode 1, ” Nursing Management 23 (December 1992) 26-30. 16. Malloch, Milton, Jobes, “A model for differentiated practice,” 20-25; Harkness, Miller, Hill, “Differentiated practice: A three-dimensional model,” 26-30. 17. American Academy of Nursing, Differentiating Nursing Practice into the Twenty-First Century, 221 -239. 18. “Resolution on the necessity for the registered nurse in the operating room,” in AORN Standards and Recommended Practices f o r Perioperative Nursing (Denver: Association of Operating Room Nurses, Inc, 1993) 27. 19. Joint Commission on the Accreditation of Healthcare Organizations, Accreditation Manual for Hospitals (Oakbrook Terrace, 111: Joint Commission on the Accreditation of Healthcare Organizations, 1993) 16-17. 20. American Academy of Nursing, Dzfferentiating Nursing Practice into the Twenty-First Century, 221-239. 21. Ihid.

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Catheter Use in Elderly Increases Hospitalization A study conducted at Ohio State University, Columbus, found that long-term use of urinary catheters in elderly patients causes infections, resultant heavy use of antibiotics, and increased hospitalization. Additionally, catheter use in some elderly nursing home residents may triple their risk of death, according to an article in the November/ December 1992 issue of Geriatric Nursing. For one year, researchers studied 1,540 elderly nursing home patients from 13 nursing homes in Columbus, Ohio. Most study participants were white females who were more than 70 years old. Results show that catheterized patients were hospitalized three times more often, stayed in the hospital three times as long, and received antibiotics about three times longer than noncatheterized patients with similar health conditions, the article states. Results also show that patients who were catheterized for most of the year were three times as likely to die as were noncatheterized patients.

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