To a Greater Influence of Nurses: Development and Implementation of a Professional Practice Model in the Netherlands

Monday, 9 November 2015: 10:40 AM

Susanne Maassen, MSc, RN
Department of Quality and Safety, Erasmus MC University Medical Center, Rotterdam, Netherlands
Gerard Brekelmans, RN, MSc
Department Education and Research, University Hospital Erasmus MC, Rotterdam, Netherlands
Annelies Sandee-Laging, RN
Department of Pediatrics, Erasmus MC-Sophia Children's Hospital University Medical Center, Rotterdam, Netherlands

Nurses are responsible for delivering patient centered qualified care. To provide this care professional nurses are needed. Working in a professional environment is an important influencing factor for nurses to fully professionalize (Laschinger, 2008). A professional nursing work environment is characterized by the following factors: (1) nurse involvement in organizational policy, (2) nurse vision and policy on quality of care, (3) nursing managers with appropriate skills, leadership style and support to nurses, (4) adequate policy in terms of staffing and resources, and (5) relationships based on equality between doctor and nurse (Lake, 2002; Arford & Zone-Smith, 2005; Laschinger, 2008).

In a university hospital in the Netherlands, with more than 2100 nurses,  the employee satisfaction surveys of 2011 and 2013 showed that nurses feel less involved in the organization's policy in comparison with other care functions. After analyzing  the surveys, we concluded that several factors for a professional nursing work environment were not present at the hospital. For example, there was no vision on nursing and nursing policy at the organizational level available. Also there is no central control on nursing principles and implementation of nursing innovations in the organization. When asked, nurses acknowledged these situation as undesirable for their own work environment and for quality of care. Nurses said that they did not feel involved in organizational policy. This feeling is confirmed in a study by Ten Holter (2011). Until the end of the twentieth century it was common that a hospital had a nurse manager and nurse leader. Through the development of hospitals into large health care organizations the position of nurse leader has been lost in favor of the managers of today. And thus also the direct influence of nurses at the administrative level (Ten Holter, 2011).  Nurses in our hospital felt a great need to change this and gain more influence on their own discipline within the organization.

In 2013 the newly founded nursing council of the hospital started with forming a vision on nursing. From American example, the nursing council decided to start working on a Professional Practice Model. A Professional Practice Model (PPM) is a visible framework that describes the professional nursing care with the aim to achieve the highest possible quality of patient care (American Nurses Credentialing Center, 2014). According Hoffart and Woods (1996) a PPM is a system that supports nurses in getting control of the nursing care and the environment in which the care is provided. A system is defined by Hoffart and Woods (1996) as structures, processes and values. ANCC (2014) indicates that a PPM is an integration of the mission and vision of nursing and nursing theory with the nursing profession. A PPM allows nurses to decide what the activities and responsibilities of nurses are and what conditions are necessary to perform these activities safely (Arford Zone & Smith, 2005). Either, a PPM gives nurses control over the operational definition of nursing in their own professional practice. Working with a PPM has positive consequences for patients, organization and nurses (Chamberlain et al., 2013). For patients advantages in terms of recovery, comfort, wellbeing and better prevention are described. These factors contribute actively to the quality and safety of patient care. Nurses themselves experience a better practice management, communication, more sense of autonomy and empowerment. Finally within organizations employee satisfaction of nurses improved and a higher level of commitment to the organization was measured (Chamberlain et al, 2013).

The development of the PPM was led by the nursing council. Input was gained by nurses from all over the organization. After creating the first concept, important stakeholders like the medical staff and the board where consulted for feedback. Also nurses reactions on the concept model were gauged. After this the model reached its final form.

The PPM consists of a core, five domains and two rings. The nurse is the core of the PPM model because the model is about the nursing profession. The five domains represent the different aspects of the nursing profession in the hospital: technical expertise, evidence based care, clinical reasoning, education and research. Nurses must have sufficient skills and competencies to perform their duties in these domains within the context of our university hospital. The inner ring, personal leadership, indicates that nurses are accountable for the operation of these domains properly. The outer ring, the professional care relationship, shows that it is necessary to establish a professional relationship with the patient. The outer ring represents also the face to the patient, communication and respect.

Working with a PPM has proven to have many advantages (Chamberlain, et al., 2013). In the Netherlands, however, it is new. Most Dutch hospitals have a vision on (nursing) care but such a concrete model that gives guidelines for a professional nursing practice environment is not being used yet. A PPM is part of the shared governance structure. These structures are currently being developed in more Dutch hospitals and the effect of shared governance on the nursing work environment and the quality of care needs a lot of research in our context. Berger, Conway and Beaton (2012) argue that nurses should use the PPM to help others understand their important and complex work. They also say that a ‘PPM is a testament to nursing’s growth and development as a profession, demonstrating increasing autonomy and control over practice…’(Berger, et al., 2012). If this is true than working with a PPM can be the solution for Dutch nurses in the process of gaining more influence on organizational level. Therefor there is a need  to study the effect of the PPM in a Dutch context.

At this point in time implementation of the PPM is started in our hospital. Part of implementation will be the study on the effect of the PPM on nurses employee satisfaction, nursing work environment and quality of patient care. By the time of the conference in November we will have our first results of the study and lessons learned from the start of the implementation of the PPM in a Dutch hospital.


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American Nurses Credentialing Centre 23 September 2014.