Glossary
EP - Exemplary Professional Practice

EP1: Professional Practice Model-Describe and demonstrate how nurses develop, apply, evaluate, adapt, and modify the Professional Practice Model

The Patient Centered Family Focused (PCFF) Care Professional Practice model facilitates the healing process. Family members are crucial in helping the patient in the recuperative process. The patient, quite naturally, is the focus of our model. Jersey City Medical Center, however, has a long history of including family members in the care plan. Liberalized visiting hours throughout the house is mutually beneficial to family members and their loved ones. Spending time with family alleviates anxiety and concerns both with the patient and the family member. Patient care teams that incorporate families are linked to effective team performance and are more customer focused in decision-making, more proactive about patient problems and more effective in working together. An atmosphere is created in which team members, patients and families can communicate comfortably and share concerns.

In 2007, our Professional Practice Model was first initiated by Mabel LaForgia (Pinto) MSN, RN, CNL, CCRN. Her Masters Capstone project was Family Focused Care in the Intensive Care Unit. It was piloted there first and then eventually implemented in the Cardiac Care Unit. The model linked Family Focused Care to effective team performance which has a positive effect on quality. With the expansion of teams to include patients and families, the organization becomes more customer focused in their decision-making, more proactive about patient problems, and more effective in working together. An atmosphere is created in which team members, patients and families can communicate comfortably and share safety concerns. With the successful implementation in the Critical Care Division, the rest of the hospital gradually adopted this approach.

The Division of Nursing next began a review of our Professional Practice model early in 2010. A committee of nurses was established who were interested in reassessing our current model in order to broaden and incorporate a new more contemporary nurse theorist; Jean Watson. The nurses participating in the group were: Elizabeth Corshu MSN, RN, Nurse Educator, Christine Pangilinan BSN, RN, Staff Nurse Psychiatry, Winnie Cherubin MSN, RN, CNL, WCC, Clinical Nurse Leader for medical-surgical units, and Cheryl Owens DNP(c), RN, CNOR Director of Nursing. The goals of the committee when developing this model were:

  1. Incorporate our Shared Governance structure in order to support decision-making
  2. Incorporate our organizational values and the four (4) pillars in order to reflect organizational support
  3. Incorporate and reassess our Care Delivery Models in order to be in alignment with our unit structure

It was determined that Jean Watson’s Transpersonal Caring was very much in line with our philosophy of patient care. Her model is congruent with the values and tenets of our nursing department. It is this connection with our patients, this compassionate care that our nurses at the Medical Center embrace.

The work of this committee did establish a relationship between the Professional Practice Model and the Care Delivery model. See the diagram below:

When determining an appropriate schematic to represent our PPM, the nursing staff was determined that they wanted something unique that portrayed nursing practice in Jersey City. They determined that the Statue of Liberty was representative of the area as well as demonstrating our excellence in patient care OO11. The schematic incorporates the values of the organization as well as our care delivery models. Staff nurses were very much a part of modifying and initiating this schematic. Christine Pangilinan BSN, RN, Critical Care Staff Nurse, developed the first schematic of our Professional Practice Model (Appendix EP1-A). The model was modified eventually by Karen Caldas MSN, RN, Risk Manager, and Cheryl Owens DNP(c), RN, CNOR to reflect just the Liberty Crown. The four pillars were added to the model to demonstrate nursing’s commitment to Quality, Engagement, Finance and Safety.

The model was first presented to the Magnet Steering Committee, consisting of Nursing Leadership, Educators and Clinical Nurse Leaders as well as the CNO (Reference EP1-A1 and EP1-A2). This forum was used to present the revised model via a slide show presentation and a review of the Patient Care Delivery systems (Reference EP1-B).

Membership Magnet Steering Committee
2010-2012

A Focus Group approach was used to evaluate and analyze the elements of the PPM with direct care nurses. Educators and Nurse Managers reviewed the proposed model with their staff, and received feedback from the staff members on prospective changes. The model was then rolled-out to the Councilor structure, for example the Professional Practice Council in order to receive commentary from this group. The model was then introduced during the Magnet Fair via posters and hand-outs explaining the elements of the model and the tenets of the Nurse Theorist. Select staff members manned the specific table where these posters were displayed and discussed the elements with other staff nurses who were participating in the Fair.

The evaluation of the Professional Practice Model can be assessed from our outcomes, particularly relating to Nurse sensitive Indicators, for example falls and pressure ulcers. We can also evaluate the success of our model via our Nurse Satisfaction and Patient Satisfaction Scores.

Nurses Adapting PCFF care model on 4 East Post Partum Unit

 
Latrese Roby BSN, RN and Brandy Tavares RN, giving bedside hand-off
  Latrese Roby BSN, RN and Brandy Tavares RN, giving bedside hand-off  

Our nurses on 4 East wanted to apply/adapt the model of care on their particular unit. Helen Im BSN, RN and Astrid Latar BSN, RN were the nurses largely responsible for propelling this forward on the Medical-surgical Units. Post Partum nurses were also determined that they would perform shift-to-shift hand-offs at the bedside and modeled this after the Medical Surgical approach. Their goal was to involve the patients in this process as well as any family members who were present. They presented this issue at their Unit Practice Council meeting and trialed it on their unit for a one (1) month period. This process was well received by the patients, nurses and family members. The hand-off is much more meaningful with the patient’s and family’s participation.

Pain Management is our GOAL They also initiated the use of whiteboards to indicate to patients when their next pain medication is due, the name of the nurse caring for them as well as the name of the patient care technician and the goal of the day. These boards are very useful in conveying important information to the patient about his/her care. Other areas of the hospital also use this approach, particularly the Medical-Surgical areas.

Establishment of a hospice room on the medical-surgical unit to apply/adapt the PCFF model

The Palliative Care nurse, Nancy Pain APN-C, recognized the need for the establishment of an in-house hospice room. Her rationale for the need for this room was that it could be used for patients that are too sick to transfer, for example, terminal extubation, or for those families that are more comfortable in the hospital setting and prefer not to change locations. It also insures that their primary physician can continue to function as their primary because of location. This room is also convenient to family members who can visit anytime of the day/evening without interrupting other patients. We also partner with Compassionate Care, a Hospice located in the nearby city of Bayonne, and a hospice nurse is dispatched on a daily basis for a four hour period. This nurse works very closely with the family and the patient. The room is decorated and furnished to add to the patient and family members comfort.

Exemplar

“A 64 year old male was brought to the Emergency Department at Jersey City Medical Center on June 18th with symptoms of hemiparesis and altered mental status. A CT scan revealed a significant hemorrhagic stroke. He was immediately taken to the operating room by neurosurgery for a craniotomy. The next day he displayed some signs of response, but that was short-lived. Several days passed with no improvement and it became painfully clear that this was a terminal event for this patient.

Palliative Care started to work with the family. This patient was very well known in Jersey City. He was a central person in his family. His wife and two adult children were constantly by his side, desperately searching for some sign of life. At some point there was discussion about a transfer to LTAC (long-term acute care), but the patient was never stable enough to be transferred. He actually was never even stable enough for a tracheotomy/percutaneous endoscopic gastrostomy tube placement (PEG) surgery. The family was stunned. They had no idea that long-term care is the financial responsibility of the family. They were, however, willing to do whatever they needed to do to provide care to their loved one.

Over many days the family, particularly the wife, came to realize that the patient would not leave the hospital. The adult children were clinging to hope. The daughter was 4 months pregnant after 19 years of trying and she could not believe that her father would never see his grandchild. The son had significant coping issues and was difficult to talk to. He was unable to stay in the conference room during discussions with the medical team and the family. This family could not agree to Do Not Resuscitate (DNR). They understood that survival was impossible but could not allow death without the effort being made to resuscitate. This was very difficult for the staff (both nurses and physicians) to accept. I felt that this was the right decision for this family and spent a lot of time with both family and staff helping them to understand this decision. There was a lot of anticipation waiting for the inevitable to happen. I encouraged the daughter to not witness the event and she was able to leave the ICU when the code began. The patient was resuscitated for 10 minutes and the patient was then pronounced. This was July 3rd, on the 15th hospital day.

The family was very grateful for the medical care and the support that they received during this 15 day hospital stay. They maintained their hope until the very end, even when the staff viewed the care as futile. For this family, the decisions they made were right for them. Many of us would not have made these same decisions, but we were able to support this family through a tragedy that they will live with for the rest of their lives.” (Submitted by Nancy Pain APN-C, Pain and Palliative Care Nurse)

Example of applying/adapting the PCFF care model in obstetrics

Lillian Reyes BS, RN Nurse Manager of Obstetrics, Randa Francis MSN, RN, CNM, WHCNP-BC Nurse Educator of Obstetrics, Michele Dickerson BSN, RN, RNC-NIC, Nurse Educator in NICU, Tara Mazzone MSN, RN, RNC-NIC Nurse Manager of NICU and April Major RN, RNC, IBCLC, Lactation Specialist are adapting the PCFF model on the obstetrical unit. They are in the process of developing a couplet/rooming-in care delivery model in obstetrics. It begins immediately after the birth of the infant. The newborn is no longer whisked away following delivery, but given to the mother for the “golden hour” to establish skin-to-skin contact with the mother. The mother is encouraged to breastfeed during this time period. Part of the plan is to establish a respite nursery that houses the infants for specific procedures and for very short time periods. The infant is to be kept with the mother the majority of the time.

Other initiatives that are being introduced in obstetrics to support the concepts of Patient Centered Family Focused Care are that a significant other is permitted in the Labor Room and is allowed 24/7 access to the mother. They also permit grandparents to visit with the infant when first born if they desire. Siblings are permitted to visit with their new brother/sister. The family unit is encouraged to stay together during the birthing process.