OO8 Aschematic of the professional practice model(s) and a description of the care delivery system(s) in use in the organization.
With the Nursing Mission and Vision statements laying down the purpose and direction, the Homestead Hospital nursing team, signified by the trunk, is able to promote a Professional Practice Model, illustrated in Exhibit 008a, that embodies its nursing philosophy. There are 5 components to the model, namely: collaboration, professional development, clinical practice, communication and care delivery system. These components are represented by the tree branches converging in the middle and cradling the nest. The nest symbolizes patient and family, the core of care, nurtured and protected by the branches. The bird represents external and internal challenges embraced by the nursing team to meet the demands of the future.
Exhibit 008a: Homestead Hospital Professional Practice Model
Collaboration
We practice collaboration in our relationships with patients & families, community and interdisciplinary team through shared decision-making.
This is demonstrated by a robust shared governance model composed of unit practice councils (UPC) in each nursing department and hospital-wide councils. The UPCs comprise of staff from different job titles within the unit. As necessary, interprofessional team members are engaged to be part of the UPC. Teamwork, collegiality, respect for diversity and community partnership are important for care coordination, which are valued and nurtured throughout the organization. (OO8 01 Homestead Hospital Shared Governance Model)
Professional Development
We are accountable for our professional development and recognize advancement through the professional nursing advancement program (PNAP) and formal recognition activities.
Nursing leaders promote the thrust for lifelong learning and individual RN accountability for keeping up with educational, licensure and competency requirements. This is supported through tuition reimbursement, scholarship programs, conference grants and free continuing education programs offered onsite and on the web. Increasing formal education and board certification is a focus in the FY 2014 Nursing Strategic Goal. (OO8 02 FY 2014 Nursing Strategic Goal) Professional accomplishments are celebrated through the PNAP and a myriad of recognition programs such as the DAISY award for extraordinary nurse, nurse of the year, certified nurses’ day, publications, pins and congratulatory letters.
Clinical Practice
We practice in an environment where quality, patient safety, evidence-based practice and research are emphasized to achieve the best patient and family outcomes.
Guided by the nursing mission statement, Homestead Hospital’s nursing staff is committed to being the leader in providing quality, safe and evidence-based care. They accomplish this with a focus on outcomes and utilization of best practice, national, regulatory and specialty guidelines in providing care. They are early adopters and often volunteer as pilot sites for new projects. They are also in the forefront of innovation and new knowledge generation by engaging in research activities.
Communication
We are in constant communication with each other, the interdisciplinary team and patients & families regarding the plan of care.
The Homestead Hospital nursing staff recognizes that effective communication is vital in providing safe care to patient and family. It is an expectation in the Baptist Health South Florida (BHSF) Service Excellence standards. Nurses utilize formal and informal channels of communications. The shared governance councils – unit based and hospital-wide – afford a more formal method where communication flows vertically and horizontally (OO8 01 Homestead Hospital Shared Governance Model). Messages are also delivered and received in staff meetings, employee and nursing forums, memos, newsletters, and emails. Nurses utilize bedside shift report, hourly rounding, interdisciplinary rounding and standardized format for hand-off communication such as Situation-Background-Assessment-Recommendation (SBAR), order read back and time-out to communicate with each other, the interprofessional team, and the patient/family.
Care Delivery System
We utilize the comfort theory and patient- and family-centered care as frameworks for care delivery.
Exhibit 008b: Homestead Hospital Care Delivery System
While the PPM is the driving force of Homestead Hospital’s nursing care, the care delivery system delineates how care is delivered. Homestead Hospital's care delivery system depicted in Exhibit 008b is a component of the PPM. It emphasizes the role of clinical nurses as primary caregivers. It delineates the nurses’ authority and accountability for clinical decision-making and outcomes of care provided based on regulatory standards such as the Nurse Practice Act and utilization of the nursing process. It further describes the resources available to the nursing staff and the importance of partnerships, shared decision-making and communication in the delivery of care.
The Homestead Hospital nursing team adopts patient-and family-centered care and comfort theory as the overarching theoretical frameworks in the care delivery system. Patient- and family-centered care is an approach to the planning, delivery, and evaluation of healthcare, which is a mutually beneficial partnership between patients, patients' families, caregivers and healthcare providers (http://www.ipfcc.org/faq.html). Its premise is based on true partnerships with patients and families. This entails involving them in care decisions and obtaining the benefits of their help and insights in the plan of care to achieve better patient/family and organizational outcomes with staff satisfaction. On the other hand, comfort theory, developed by Dr. Katharine Kolcaba, RN, has its major underpinning in the holistic comfort needs that human beings have. She advocates that it is an important mission for the healthcare team to meet these comfort needs. When patients and families experience enhance comfort, they engage in health-seeking behaviors that lead to better outcomes and institutional integrity. Homestead Hospital nurses have fully embraced these concepts because of the unique opportunity, through interactions with patients and families, in partnering with and meeting their holistic comfort needs.
With the overall frameworks described above as general guide to nursing practice, the care delivery models differ from one department to another. It is tailored to the unit’s specialty standards; patient population’s needs; staff composition and competency; and accommodations for continuity of care. Exhibit 008c below outlines the care delivery models used in different nursing units followed by a brief explanation of specialty standards adopted.
Exhibit 008c: Homestead Hospital Care Delivery Models
Department |
Care Delivery Models |
3 South, Med-Surg and Orthopedic |
Team nursing |
Med-Surg 4, Med-Surg, Oncology and Pediatric |
Team nursing; primary nursing with chemotherapy administration |
Med-Surg 5, Chest Pain and Observation |
Team nursing |
ICU, Critical Care |
Team nursing |
PCU, Step-down |
Team nursing |
ED, Main |
Team nursing |
ED, Pediatric |
Team nursing |
Ambulatory Surgery, Outpatient wound care and IV infusions |
Team nursing |
Endoscopy |
Team nursing |
OR |
Team nursing |
PACU |
Primary nursing |
Perinatal Services |
Family-centered couplet care, team and primary nursing |
Imaging/Cardiology Nurses |
Primary nursing with each procedure |
Peripherally-inserted Centralized Catheter (PICC) Team |
Primary nursing with each procedure |
Nursing Care in Intensive Care Unit (ICU) and Progressive Care Unit (PCU) is based on American Association of Critical Care Nurses (AACN) Guidelines
Cognizant that families undergo undue stress with their loved ones in critical condition, nurses uphold patient-and family-centered care by involving patient and families in bedside shift report and interdisciplinary rounds; instituting open visitation; accommodating overnight stays of a significant other; allowing family presence in emergency situations and procedures; and being proactive with palliative care consultation, when needed. They also pay attention to comfort by making design changes in the family waiting lounge; providing patient comfort measures and pain management; and allowing for pet therapy and pastoral care visits.
The RN nursing team in the ICU and PCU utilizes the team nursing model. Clinical partners (CPs) assist the nurses in providing basic nursing care such as turning, bed baths and vital signs while unit clerks and ancillary team members provide additional support. In ICU, the patient to RN ratio is 2:1. When the patient is critically ill such as therapeutic hypothermia and cardiac arrest patients, a 1:1 ratio is maintained.
Initially, there was no staff devoted solely for PCU. ICU nurses were floated to PCU and during times of increased staffing needs, some medical-surgical nurses were asked to work there. This became one of the early projects tackled by the ICU/PCU unit practice council. After researching for best practices, such as the ACCN guidelines for PCU staffing, they were able to advocate for additional RN full-time equivalents (FTEs) that were budgeted and approved in fiscal year 2012. This enabled the unit to maintain staffing at 4:1 patient to nurse ratio with dedicated PCU RNs under a new cost center. This led to enhanced patient care and increased staff satisfaction. In 2013, the department celebrated its first progressive care certified RN.
Nursing Care in the Emergency Department (ED) is based on Emergency Nursing Association (ENA) Guidelines
Homestead Hospital’s ED is the second busiest in Miami-Dade County seeing close to 90,000 visits per year. Despite the hectic pace, the ED nursing team promotes comfort by informing the patient and family about their treatment plan to alleviate anxiety using AIDET (Acknowledge, Introduce, Duration, Explanation, and Thank You). They pay particular attention to discharge instructions tailored to the patient’s cultural needs and with family involvement to minimize unnecessary ED return visits. More recently, ED UPC implemented discharge call backs within 48 hours of discharge. This has been received positively by the patients as evidenced by an improvement in the department’s patient satisfaction scores.
ED nurses utilize the team nursing model. Registered nurses direct ED technicians and ancillary team members in providing care to the patients. Based on ENA staffing guidelines, the patient to RN ratio is maintained at 4:1 with adjustments made according to acuity. For example, if a nurse is holding an ICU admission, she may have another ICU hold. However, in the case of an acute critically ill patient who has vasoactive drips, intubated, on therapeutic hypothermia or moderate sedation, a 1:1 patient to RN ratio is kept until the patient is stable.
Nursing Care in Endoscopy, Operating Room (OR) and Post-Anesthesia Care Unit (PACU) are based on the Society of Gastroenterology Nurses and Associates (SGNA), Association of Perioperative Registered Nurses (AORN) and the American Society of Perianesthesia Nurses (ASPAN) Guidelines
Our perioperative nurses provide high quality, compassionate care to surgical patients who are often anxious about their procedures. Nurses provide special attention to pre-operative teaching prior to and on the day of surgery to diminish fear and anxiety among patients and families. Families are also included in the hand-off report as the patient moves through the different perioperative phases and the discharge teaching to promote compliance with the treatment plan. The team provides families with beepers and phone numbers while waiting in the family lounge to facilitate communication with the surgical team. To promote comfort, controlled forced air warming gown is given to the patient to prevent hypothermia; pain assessment/reassessment is conducted frequently; and comfort measures are instituted such as repositioning and using ice packs.
Endoscopy nurses use the team nursing model. They are responsible for ensuring patients are adequately prepared prior to the procedure and collaborate with the medical and anesthesia teams during the procedure and recovery phases. To align with SGNA guidelines, 2 persons are allocated during the endoscopy procedure, 1 of whom must be a RN caring for the patient. Surgical nurses use a combination team and primary approaches while caring for patients in the perioperative continuum. The OR nurses coordinate the care provided by the anesthesia and surgical teams. Consistent with AORN guidelines, 2 persons assist in each surgical procedure, 1 circulating RN & 1 scrub person, who can be either a surgical technologist or a RN. PACU nurses provide primary care to the patients during the different phases of post-anesthesia recovery. Maintaining a 2:1 nurse patient ratio, based on ASPAN recommendations, allows the nurse to care for 1 unconscious stable patient and 1 conscious stable but uncomplicated patient over 8 years of age. The ratio is reduced to 1:1 when caring for patients under 8 years old and any unstable patient regardless of age.
Nursing Care in Perinatal Services is based on Association of Women's Health, Obstetric and Neonatal Nurses (AWHONN) Guidelines
The birth of a baby is mostly celebrated as a joyous occasion by the entire family. To accommodate maximum family involvement while still providing safe care to mother and baby, the nursing team has recently revised its visitation policy to more fully encompass patient-and family-centered care. Mothers have the option to designate who they want to be present throughout their stay. Significant others are provided sleep chairs for comfort. Siblings are also allowed to visit. Skin-to-skin contact of the newborn with the mom is initiated as soon as possible after vaginal and cesarean section deliveries. This is an important precursor to breastfeeding and promotes comfort of the baby. Mothers and babies are not separated unless the mother requests or the infant requires more intensive observation in the nursery setting. Additionally, the nursing team is proactive in meeting mom and baby comfort needs throughout the birthing process by providing pain management options to mothers especially those who want to deliver naturally; providing constant reassurance and coaching to patient and significant other; and maintaining newborn normothermia.
Perinatal services subscribe to the AWHONN staffing guidelines and adjust the care delivery model as the mother transitions from initial presentation to discharge. In order to adequately staff the units, all L&D RN’s are oriented to and competent in labor and delivery (L&D), OR and PACU. In initial triage, primary nursing is utilized where 1 RN is assigned to 1 woman presenting for care. This ratio may change to 1 nurse to 2-3 women as maternal-fetal status is determined to be stable until patient disposition. As the woman moves into the inpatient antepartum area, team nursing is utilized and 1 nurse is assigned to 3 women if in stable condition. This assignment is reduced to 1:1 if the patient is unstable or 1:2 when the patient is receiving pharmacologic agents that require fetal monitoring. Primary nursing is used in the L&D room and immediate post-partum phase for normal deliveries where 1 nurse is allocated to care for the mother and another one for the baby. Once the mother and infant are stable, the primary nurse assumes the couplet for the remainder of the transition. The Perinatal OR/PACU areas adhere to the AORN and ASPAN guidelines described above. When mother and baby moves into the post-partum unit, the couplet care delivery model is implemented and 1 nurse is assigned to 2-4 pairings of mixed acuity with care partner support. Neonates requiring ongoing care are moved into the “sick newborn” nursery where a primary nurse cares for 3-4 newborns. This ratio becomes 1:1 for high acuity transfers to higher levels of care. There is also a dedicated lactation resource nurse to assist with complicated breastfeeding issues and a childbirth educator who conducts discharge classes.
Summary Attachments/Hyperlinks/Evidences:
OO8 01 Homestead Hospital Shared Governance Model
OO8 02 FY 2014 Nursing Strategic Goal
Exhibit 008a: Homestead Hospital Professional Practice Model
Exhibit 008b: Homestead Hospital Care Delivery System
Exhibit 008c: Homestead Hospital Care Delivery Models
Next Page: OO9