Building an Environment for Nursing Practice
In the summer of 2006, Department of Nursing began a journey to develop principles for a model of nursing practice and care delivery at Brigham and Women’s Hospital. These initiatives called, “Finding the Good” and “Defining the Good,” began in clinical areas throughout BWH. Nurse managers conducted focus groups with more than 300 nurses identified by their peers and colleagues as being clinically knowledgeable, technically skilled and highly effective in working with all members of the health care team. In the focus groups, these expert nurses were asked to describe what good care looked like and what processes or systems allow them to deliver good care to their patients and families.
Four themes consistently emerged as hallmarks of excellent nursing practice at BWH:
1. Sustained relationships with patients and families through which the patient feels known and cared for. By developing a relationship based on trust, these nurses came to know their patients and families in an authentic way and were able to work with them to achieve desired outcomes of care. Because they knew the particular aspects of their patient’s clinical situation and responses to treatment, these nurses were able to recognize and communicate subtle changes in the patient’s condition to facilitate collaboration and timely appropriate intervention by all members of the team. Knowing the patient was essential for these nurses to make a difference to patient outcomes and to develop their own clinical knowledge and skill. It was the core of their professional work and provided the framework for the caring practices which ultimately made a difference to their patients and families.
2. Relationships with the team where nurses are perceived as full partners in all aspects of the care of the patient and family. These nurses recognized their contribution to the team as bringing critically important knowledge and judgment to bear on the assessment of the patient’s clinical situation and responses to treatment. The nurse’s central place within the patient care team positioned him or her to coordinate the treatment plan for the patient and family and, oftentimes, to lead and influence the reasoning of colleagues in the patient’s best interest. These nurses were aware of the strengths and weaknesses of each member of the team, and they knew how to stay engaged and involved to get the patient and family what they needed.
3. Communication with team members that is open, honest and collaborative. Grounded in the belief that patients and families received the best care when perspectives of different team members were integrated, these nurses worked to understand the specific contributions of each discipline and engaged in behavior that promoted and preserved the functioning of the team. From having consistent insight into his or her own behavior and from understanding the behavior of others, these nurses communicated and built relationships by offering and being open to constructive feedback and advice.
4. Commitment to building a practice environment that is professional, mutually respectful and supportive. These nurses were intellectually curious and fostered clinical inquiry among their colleagues. They functioned autonomously and assumed responsibility for their own professional development.
They also placed high value on visible and informed leadership that facilitated their ability to provide care. While these expert nurses acknowledged the importance of having good systems and processes in place, they did not allow the absence of systems or processes to serve as barriers to providing care.
Where We Are Now
The Department of Nursing is now building on the work of “Defining the Good.” In July, Essence of Nursing Award nominees and recipients from the past three years were invited to participate in practice discussions facilitated by Patricia Hooper Kyriakidis, PhD, RN, co-author of Clinical Wisdom in Critical Care, and Mary Lou Etheredge, PMHCNS-BC, director of Nursing Practice Development. Essence finalists Rhonda Martin, RN, Nancy Olsen Bailey, RN, Corrine Cyr Pryor, RN, Mary Beth Mondello, RN, Marion Fitzgerald, RN, Joan Dorr, RN, Karen Green RN, and Mary Anne Bennett, RN participated in the discussion along award recipients Beth Baldwin, RN, Margaret Costello, RN, and Ellie Ericson, RN.
These discussions focused on patient situations where the nurse made a difference or patient situations that for whatever reason were memorable. From these discussions, current themes will be validated and enriched so that nursing practice will be built around what BWH nurses describe as excellent practice in order to provide excellent care.
What’s Next?
By describing the richness and skill embedded in their everyday practice, the expert nurses who participated in these initiatives have provided the foundational work for creating a professional practice model at BWH. The findings of these initiatives prepare BWH Nursing for the next phase of this ongoing work: the addition of a Nursing Practice Committee to the existing committee structure. The Nursing Practice Committee will deliberate about the hallmarks of expertise described by expert nurses, how to integrate these elements into the practice of all nurses at BWH and what the environment of care should be to facilitate excellent care. This committee will give us a place to talk about the care of patients and families and the key elements that need to be in place to support the nurse-patient relationship, so the right educational opportunities, systems and processes are in place. The professional practice model of the future is being built by the nurses at BWH today.