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Project Team identifies practice model criteria
AORN JOURNAL
OCI‘OHEK 19YZ. \’Ol. 56-
Project Team identifies practice model criteria
T
he Project Team to Identify New Practice Models for Perioperative Nursing is part of AORN’s Project 2000. The Project Team, which reports to the Project 2000 Steering Committee, is composed of a chairman and at least three members who are appointed annually. One member of the Project Team serves as a liaison to the Steering Committee. The original charges to the Project Team were to identify models of nursing care delivery, identify how those models could look and work in a perioperative environment, disseminate this information to AORN members, and 0 study the feasibility of funding or procuring funds for demonstration projects. The Project Team has completed a comprehensive review of literature on nursing care delivery models and practice modcls, including primary care models, professional models, independent (ie, private) practitioner models, and extender personnel, team, functional, and modified models. From this review, the team identified 12 criteria that ate important to a nursing care delivery model (Table 1 ). None of the models reviewed, however, contained all 12 criteria.
Reaction, Advisory Panels
T
o identify how models could work in perioperative settings, the Project Team asked its reaction panel and advisory panel members to identify what perioperative nurses believe 630
are important components of a nursing care delivery model. A reaction panel is composed of AORN members chosen randomly from the membership roster. They are asked to respond to proposed outcomes and goals of each Project 2000 Project Team. Advisory panels are composed of experts in each of the Project Team’s subject areas. They assist the teams in their deliberations and provide consultation and advice. The panels help the Project Teams stay on course. A work sheet listing the 12 criteria was mailed to 13 advisory panel members and 250 reaction panel members. The panel members were asked for their opinions on what is iniportant in a perioperative model of nursing care delivery. The descriptions of the criteria are shown in Table 2. All panel members were asked to mark “yes” if they believe the criteria are important or “no” if they believe they are nor important. Twenty percent of the reaction panel members and 92% of the advisory panel members responded. The 12 advisory panel respondents and 45 of the 49 reaction panel respondents marked “yes,” the 12 criteria are important. The Project Team then asked respondents whether they strongly disagreed. disagreed, agreed, strongly agreed, or were uncertain about the importance of each of the criteria. which could be included in a perioperative nursing care delivery model. The results are shown in Table 3. The advisory panel respondents chose “establishes a framework for standards” as the most important criterion, followed
by “professional autonomy I and accountability.” In placTable I ing “patient acuity” as the I Criteria f o r least important, five of the Models of Nursing Care Delivery I 12 respondents marked ”uncertain”: therefore, the The Project Team identified that nursing care delivery models Project T e a m members should address believe the opinion could be 1. patient outcomes, due more to lack of knowl2. nursing competencies, edge of acuity ratings than 3. role definition and differentiation of practice, the perception of importance 4. patient acuity, in a model for perioperative 5. professional knowledge base, practice. It is interesting to 6. professional autonomy and accountability, note that for the critcrion 7. multidisciplinary and collaborative objectives, ‘YinanciaVbudgetary impact,” 8. financial/budgetary impact, five members of the advisory 9. legal/medical ramifications, panel strongly agreed, three 10. a framework for standards, agreed, three were undecid1 1. applicability, flexibility, and replicability, and ed, and one disagreed. Most 12. health care promotion/self-determination trends. of the literature reviewed by I the Proiect Team. however. terion. The Project Team members raised quesidentifies cost, either direct or indirect, as one tions about the meaning of the responses. Does of the major reasons for developing a specific there need to be more education about the ecomodel lor practice. nomic realities of today? Are there differences Results from the reaction panel to the 12 criin opinion because of individual organizational teria were somewhat different from the advisocultures and the ability to institute professional ry panel results. The members of the reaction standards? Are the opinions caused by different panel identified “professional autonomy and interpretations of the criteria meaning and defiaccountability“ as the most important criterion. nitions by the advisory and reaction panels‘? “Financial/budgetary impact” was rated as the There seems to be a consensus of opinion least important criterion. The responses from about the criteria of “nursing competencies” the reaction panel on the question of budget and “patient acuity.” They were closely ranked importance were as follows: 13 strongly by the two groups. agreed, 23 agreed, seven were uncertain, four disagreed, and two strongly disagreed. SpeciJc Models The Project Team reviewed the opinions of the advisory and reaction panels and identified ach Project Team member is responsible several concerns regarding priorities and for obtaining information about a particular importance of criteria. The criteria with signifimodel. In this phase, each team member will cant differences were “patient outcomes” and work with two or three advisory panel mem“fiiiancial/budgetary impacc.” This may be bers for input on his or her specific model. The because opinions came from a variety of setadvisory panel members will receive refertings in which care delivery focus varies (ie, ences, the model summary, and selected artifocus on the patient, nurse, institution). cles for that model. They will review the inforRegardless of the focus of the nursing care mation and provide feedback to the Project delivery model, the Project Team noted some Team member regarding their opinions about concern with the low priority given by both the importance and application of the model to panels to the “financial/budgetary impact” cri-
E
cr 631
OCTOBER 1992. VOL 56, NO 4
AORN JOURNAL
Table 2
Descriptions of Patient outcomes: Patient outcomes measure the results and quality of patient care and are viewed as the achievement of a preestablished patient goal. Patient outcomes niay be written as a patient outcome standard. So nurses can judge the degree to which the standard has been met. they may be written in measurable terms. Nursing competencies: Nursing competency is defined as fundamental knowledge and skills required to render safe patient care. Nursing competencies can be written in either behavioral terms or process standards format. Nursing competencies can be graded in scales such as "basic to advanced" or "novice to expert." Role definition and differentiation of practice: Professional nursing roles are clearly defined and are differentiated from technical roles. Concepts of a nursing career ladder are well outlined and are differentiated from a technical ladder or a medical model. Roles should be defined and differentiated by productivity. process. and outcome standards. Roles reflect aspects of functional/ physical care (decision making). Clear progression and differentiation is seen. Patient acuity: Patient acuity usually is defined by tools developed to measure the degree/severity of a patient's illness or the nursing activity intensity for a patient. Patient acuity systems generally are used to determine the complement of staff required to care for a patient.
634
patient type, or patient population. Patient acuity systems are constructed with some form of criteria and scoring system that enables the nurse(s) to classify a patient. patient type, or population.
Professional knowledge base: The knowledge base of a professional nurse is received through formal and informal education (ie. experiential). The knowledge base evolves through continual scientific research and quantitative analysis; development of conceptional franieworks/nursing theories; and the advancement of information dissemination, relationships, and classification. The knowledge base directly relates to decision making, regarding the control and utilization of resources. The knowledge base can best be measured by its quantity, quality. distribution, flexibility, and differentiation (generalized versus specialized). Professional autonomy and accountability: These refer to the degree the professional nurse functions independently and is accountable for his or her actions. They refer to the freedom (within the scope of practice) with which the professional nurse is allowed to carry out his or her professional responsibilities. Multidisciplinary and collaborative objectives: This is the multidisciplinary approach to patient care. Collaboration involves designing work roles/structure to maximize expertise and patient outcomes. It involves all disciplines/departments
OCTOBER 1992, VOL 56, NO 4
AORN JOURNAL
Nursing Model Criteria working toward organizational and patient goals. It refers to physicians and nurses working together to achieve positive patient outcomes within appropriate time frames and with economic resource utilization.
FinanciaVbudgetary impact: This is the quantitative measure of a nursing care delivery system via its financial performance or budgetary impact. Examples of quantitative measures are length of stay, cost per case, number of readmissions, positive or negative changes in reimbursement, and cost of nursing recruitment and retention. It is a measure of productivity (ie, case turnover time, increase in volume). It is the maximum utilization of human and other resources.
include total quality management concepts and quality assessment indicators such as morbidity and mortality; patient satisfaction; and preoperative, intraoperative, and postoperative indicators/ complications (ie, infection, airway management, pain control, hemodynamic status, mobility, returns to OR, status upon discharge, counts). It includes the return of the maximum level of wellness and/or function of a patient and includes nurse job satisfaction.
LegaVmedical ramifications: This refers to the impact a patient care delivery model would have on the following: expansion or contraction of nursing role(s); licensure; scope of practice; requirements for additional certification, examinations, or education; infringement on practice of another discipline (ie, physician[s]); changes in standards of patient care; changes in level(s) of practice in both professional nursing roles and technical roles.
Applicability, flexibility, and replicability : This refers to whether the patient care delivery system is applicable to all clinical/nursing departments, health care organizations and patient types. Can the nursing/patient care delivery system meet the needs of the inpatient and outpatient, critical patient, and well patient? Can this nursing/patient care delivery system be replicated across the country in a variety of health care settings, organizational structures, and multicultural environments? The nursing/patient care delivery system should be flexible and dynamic so that it can meet the changes posted by changes in technology, knowledge, and health care.
A framework for standards: The perioperative nursing model should establish a framework for patient/nursing standards from which systems of quality control and improvement can evolve. This model should integrate and collaborate with physician- and organization-wide quality assessment and improvement efforts. The model should
Health care promotion/selfdetermination trends: This encompasses the changing trend in health care toward health promotion and disease prevention in addition to the care of the sick. Self-determination refers to the awareness of support of the patient’s right to determine facets of his or her own health care.
635
Table 3
Responses to Identified Criteria f o r Nursing Care Delivery Models Criteria as identified in existing models
Order of importance by advisory panel
I . Patient outcomes 2. Nursing competencies 3. Role definition and differentiation of practice -1. Patient acuity 5 . Professional knowledge base 6. Professional autonomy and accountability 7. Multidisciplinary and collaborative objectives 8. Financial/budgetary impact 9. Legal/medical ramifications i 0. A framework for standards 1 1. Applicability, flexibility. and replicability 12. Health care promotion/ self-determination trends
Order of importance by reaction panel
6 3'
2 3
4 10
10 11
3. 2
7
3' 9 7 1
4 12 5 6
5
8
8
9
1
'These three criteria were rated equally important by advisory panel members.
perioprrative nursing. The 12 identified criteria, which were refined based on input from the panels. will be used as the basic framework, but the advisory panel members may comment on any aspect they consider important. After the second round of input from the advisory panel. each Project Team member will write an article about a specific model for the AORN Jorrrtitrl. The fourth goal (ie. funding for demonstration projects) will be considered at a later date. The members of the Project Team extend their thanks and appreciation to all those who responded to the survey. The opinions and input of all members is valued highly. If anyone wishes to comment on any aspect of this report. the criteria for nursing care delivery systems. or other aspects. please write to the Project Team to Identify New Practice Models, 6.36
c/o Dorothy Fogg, AORN Headquarters, 10170 E Mississippi Ave, Denver, CO 80231. NANCY GIRARD, RN, MSN, CNOR, CHAIRMAN VICKIFOX,RN, MSN, CNOR LINDAGROAH,RN. MS, CNOR, CNA VIVIAN JAEGER,RN, MA JANETLEWIS,RN, MA, CNOR BRENDA MCKONLY, RN, MS, CNOR MARKPHIPPEN, RN, MN, CNOR. LIAISON TO STEERING COMMITTEE DOROTHY FOGG,RN. MA. STAFFCONSULTANT PROJECT TEAMTO IDENTIFY NEWPRACTICE MODELSFOR PERIOPERATIVE NURSING M e r d x w are iirged to send qitestioris regarding Ito the Editor. AORN Journal, 10170 E Project " MismJippi A\.e, Detri er, CO 80231.
OCI‘OHEK 19YZ. \’Ol. 56-
Project Team identifies practice model criteria
T
he Project Team to Identify New Practice Models for Perioperative Nursing is part of AORN’s Project 2000. The Project Team, which reports to the Project 2000 Steering Committee, is composed of a chairman and at least three members who are appointed annually. One member of the Project Team serves as a liaison to the Steering Committee. The original charges to the Project Team were to identify models of nursing care delivery, identify how those models could look and work in a perioperative environment, disseminate this information to AORN members, and 0 study the feasibility of funding or procuring funds for demonstration projects. The Project Team has completed a comprehensive review of literature on nursing care delivery models and practice modcls, including primary care models, professional models, independent (ie, private) practitioner models, and extender personnel, team, functional, and modified models. From this review, the team identified 12 criteria that ate important to a nursing care delivery model (Table 1 ). None of the models reviewed, however, contained all 12 criteria.
Reaction, Advisory Panels
T
o identify how models could work in perioperative settings, the Project Team asked its reaction panel and advisory panel members to identify what perioperative nurses believe 630
are important components of a nursing care delivery model. A reaction panel is composed of AORN members chosen randomly from the membership roster. They are asked to respond to proposed outcomes and goals of each Project 2000 Project Team. Advisory panels are composed of experts in each of the Project Team’s subject areas. They assist the teams in their deliberations and provide consultation and advice. The panels help the Project Teams stay on course. A work sheet listing the 12 criteria was mailed to 13 advisory panel members and 250 reaction panel members. The panel members were asked for their opinions on what is iniportant in a perioperative model of nursing care delivery. The descriptions of the criteria are shown in Table 2. All panel members were asked to mark “yes” if they believe the criteria are important or “no” if they believe they are nor important. Twenty percent of the reaction panel members and 92% of the advisory panel members responded. The 12 advisory panel respondents and 45 of the 49 reaction panel respondents marked “yes,” the 12 criteria are important. The Project Team then asked respondents whether they strongly disagreed. disagreed, agreed, strongly agreed, or were uncertain about the importance of each of the criteria. which could be included in a perioperative nursing care delivery model. The results are shown in Table 3. The advisory panel respondents chose “establishes a framework for standards” as the most important criterion, followed
by “professional autonomy I and accountability.” In placTable I ing “patient acuity” as the I Criteria f o r least important, five of the Models of Nursing Care Delivery I 12 respondents marked ”uncertain”: therefore, the The Project Team identified that nursing care delivery models Project T e a m members should address believe the opinion could be 1. patient outcomes, due more to lack of knowl2. nursing competencies, edge of acuity ratings than 3. role definition and differentiation of practice, the perception of importance 4. patient acuity, in a model for perioperative 5. professional knowledge base, practice. It is interesting to 6. professional autonomy and accountability, note that for the critcrion 7. multidisciplinary and collaborative objectives, ‘YinanciaVbudgetary impact,” 8. financial/budgetary impact, five members of the advisory 9. legal/medical ramifications, panel strongly agreed, three 10. a framework for standards, agreed, three were undecid1 1. applicability, flexibility, and replicability, and ed, and one disagreed. Most 12. health care promotion/self-determination trends. of the literature reviewed by I the Proiect Team. however. terion. The Project Team members raised quesidentifies cost, either direct or indirect, as one tions about the meaning of the responses. Does of the major reasons for developing a specific there need to be more education about the ecomodel lor practice. nomic realities of today? Are there differences Results from the reaction panel to the 12 criin opinion because of individual organizational teria were somewhat different from the advisocultures and the ability to institute professional ry panel results. The members of the reaction standards? Are the opinions caused by different panel identified “professional autonomy and interpretations of the criteria meaning and defiaccountability“ as the most important criterion. nitions by the advisory and reaction panels‘? “Financial/budgetary impact” was rated as the There seems to be a consensus of opinion least important criterion. The responses from about the criteria of “nursing competencies” the reaction panel on the question of budget and “patient acuity.” They were closely ranked importance were as follows: 13 strongly by the two groups. agreed, 23 agreed, seven were uncertain, four disagreed, and two strongly disagreed. SpeciJc Models The Project Team reviewed the opinions of the advisory and reaction panels and identified ach Project Team member is responsible several concerns regarding priorities and for obtaining information about a particular importance of criteria. The criteria with signifimodel. In this phase, each team member will cant differences were “patient outcomes” and work with two or three advisory panel mem“fiiiancial/budgetary impacc.” This may be bers for input on his or her specific model. The because opinions came from a variety of setadvisory panel members will receive refertings in which care delivery focus varies (ie, ences, the model summary, and selected artifocus on the patient, nurse, institution). cles for that model. They will review the inforRegardless of the focus of the nursing care mation and provide feedback to the Project delivery model, the Project Team noted some Team member regarding their opinions about concern with the low priority given by both the importance and application of the model to panels to the “financial/budgetary impact” cri-
E
cr 631
OCTOBER 1992. VOL 56, NO 4
AORN JOURNAL
Table 2
Descriptions of Patient outcomes: Patient outcomes measure the results and quality of patient care and are viewed as the achievement of a preestablished patient goal. Patient outcomes niay be written as a patient outcome standard. So nurses can judge the degree to which the standard has been met. they may be written in measurable terms. Nursing competencies: Nursing competency is defined as fundamental knowledge and skills required to render safe patient care. Nursing competencies can be written in either behavioral terms or process standards format. Nursing competencies can be graded in scales such as "basic to advanced" or "novice to expert." Role definition and differentiation of practice: Professional nursing roles are clearly defined and are differentiated from technical roles. Concepts of a nursing career ladder are well outlined and are differentiated from a technical ladder or a medical model. Roles should be defined and differentiated by productivity. process. and outcome standards. Roles reflect aspects of functional/ physical care (decision making). Clear progression and differentiation is seen. Patient acuity: Patient acuity usually is defined by tools developed to measure the degree/severity of a patient's illness or the nursing activity intensity for a patient. Patient acuity systems generally are used to determine the complement of staff required to care for a patient.
634
patient type, or patient population. Patient acuity systems are constructed with some form of criteria and scoring system that enables the nurse(s) to classify a patient. patient type, or population.
Professional knowledge base: The knowledge base of a professional nurse is received through formal and informal education (ie. experiential). The knowledge base evolves through continual scientific research and quantitative analysis; development of conceptional franieworks/nursing theories; and the advancement of information dissemination, relationships, and classification. The knowledge base directly relates to decision making, regarding the control and utilization of resources. The knowledge base can best be measured by its quantity, quality. distribution, flexibility, and differentiation (generalized versus specialized). Professional autonomy and accountability: These refer to the degree the professional nurse functions independently and is accountable for his or her actions. They refer to the freedom (within the scope of practice) with which the professional nurse is allowed to carry out his or her professional responsibilities. Multidisciplinary and collaborative objectives: This is the multidisciplinary approach to patient care. Collaboration involves designing work roles/structure to maximize expertise and patient outcomes. It involves all disciplines/departments
OCTOBER 1992, VOL 56, NO 4
AORN JOURNAL
Nursing Model Criteria working toward organizational and patient goals. It refers to physicians and nurses working together to achieve positive patient outcomes within appropriate time frames and with economic resource utilization.
FinanciaVbudgetary impact: This is the quantitative measure of a nursing care delivery system via its financial performance or budgetary impact. Examples of quantitative measures are length of stay, cost per case, number of readmissions, positive or negative changes in reimbursement, and cost of nursing recruitment and retention. It is a measure of productivity (ie, case turnover time, increase in volume). It is the maximum utilization of human and other resources.
include total quality management concepts and quality assessment indicators such as morbidity and mortality; patient satisfaction; and preoperative, intraoperative, and postoperative indicators/ complications (ie, infection, airway management, pain control, hemodynamic status, mobility, returns to OR, status upon discharge, counts). It includes the return of the maximum level of wellness and/or function of a patient and includes nurse job satisfaction.
LegaVmedical ramifications: This refers to the impact a patient care delivery model would have on the following: expansion or contraction of nursing role(s); licensure; scope of practice; requirements for additional certification, examinations, or education; infringement on practice of another discipline (ie, physician[s]); changes in standards of patient care; changes in level(s) of practice in both professional nursing roles and technical roles.
Applicability, flexibility, and replicability : This refers to whether the patient care delivery system is applicable to all clinical/nursing departments, health care organizations and patient types. Can the nursing/patient care delivery system meet the needs of the inpatient and outpatient, critical patient, and well patient? Can this nursing/patient care delivery system be replicated across the country in a variety of health care settings, organizational structures, and multicultural environments? The nursing/patient care delivery system should be flexible and dynamic so that it can meet the changes posted by changes in technology, knowledge, and health care.
A framework for standards: The perioperative nursing model should establish a framework for patient/nursing standards from which systems of quality control and improvement can evolve. This model should integrate and collaborate with physician- and organization-wide quality assessment and improvement efforts. The model should
Health care promotion/selfdetermination trends: This encompasses the changing trend in health care toward health promotion and disease prevention in addition to the care of the sick. Self-determination refers to the awareness of support of the patient’s right to determine facets of his or her own health care.
635
Table 3
Responses to Identified Criteria f o r Nursing Care Delivery Models Criteria as identified in existing models
Order of importance by advisory panel
I . Patient outcomes 2. Nursing competencies 3. Role definition and differentiation of practice -1. Patient acuity 5 . Professional knowledge base 6. Professional autonomy and accountability 7. Multidisciplinary and collaborative objectives 8. Financial/budgetary impact 9. Legal/medical ramifications i 0. A framework for standards 1 1. Applicability, flexibility. and replicability 12. Health care promotion/ self-determination trends
Order of importance by reaction panel
6 3'
2 3
4 10
10 11
3. 2
7
3' 9 7 1
4 12 5 6
5
8
8
9
1
'These three criteria were rated equally important by advisory panel members.
perioprrative nursing. The 12 identified criteria, which were refined based on input from the panels. will be used as the basic framework, but the advisory panel members may comment on any aspect they consider important. After the second round of input from the advisory panel. each Project Team member will write an article about a specific model for the AORN Jorrrtitrl. The fourth goal (ie. funding for demonstration projects) will be considered at a later date. The members of the Project Team extend their thanks and appreciation to all those who responded to the survey. The opinions and input of all members is valued highly. If anyone wishes to comment on any aspect of this report. the criteria for nursing care delivery systems. or other aspects. please write to the Project Team to Identify New Practice Models, 6.36
c/o Dorothy Fogg, AORN Headquarters, 10170 E Mississippi Ave, Denver, CO 80231. NANCY GIRARD, RN, MSN, CNOR, CHAIRMAN VICKIFOX,RN, MSN, CNOR LINDAGROAH,RN. MS, CNOR, CNA VIVIAN JAEGER,RN, MA JANETLEWIS,RN, MA, CNOR BRENDA MCKONLY, RN, MS, CNOR MARKPHIPPEN, RN, MN, CNOR. LIAISON TO STEERING COMMITTEE DOROTHY FOGG,RN. MA. STAFFCONSULTANT PROJECT TEAMTO IDENTIFY NEWPRACTICE MODELSFOR PERIOPERATIVE NURSING M e r d x w are iirged to send qitestioris regarding Ito the Editor. AORN Journal, 10170 E Project " MismJippi A\.e, Detri er, CO 80231.