A Professional Practice Model provides the framework for achieving clinical outcomes, and is driven by critical thinkers and strong decision-makers.

Key Components:

• Values that affirm our work
• Philosophy statement that synthesizes our beliefs
• Standards of practice
• Decision-making that empowers clinicians
• Professional development, including career-advancement programs
• Patient-care delivery system
• Privileging, credentialing and peer-review systems
• Research-based practice
• Theories from profession-specific experts

DESCRIPTIVE-THEORY MODELS
Theory is a term we all use regularly. However, putting theory into practice is not an idea we often discuss. The challenges of our current practice environment present us with an opportunity to reflect on our practice-to articulate the "whys" of what we do. Understanding the philosophical and theoretical foundation of our practice is an important part of professional development and the overall change processes we are undertaking.

Theory provides a vision of the central concepts of any discipline. Theory construction is essential in all disciplines as it helps to describe, explain, predict and prescribe phenomena and situations. Clinicians use theories as a means of guiding their practice and influencing their interventions. Other models have demonstrated that practice, which is guided by theory, is consistent because clinicians are given a framework by which to view situations and plan care. When clinicians interact with patients and other members of the healthcare team, they are giving life to the assumptions, beliefs and concepts that make up a theory.

Theories exist to explain critical concepts and to describe the relationships that connect those concepts. For example, a theory would guide how a practitioner connects pieces of a puzzle. First, theory helps to identify which piece(s) of the puzzle a practitioner is accountable for connecting. Then, it may help to determine which pieces the practitioner is to start with. It is a guide that helps us to get to the clearest picture in the shortest amount of time. The strength and direction of those connections are constantly shaped and challenged by ongoing practice and research. If pieces that appear to fit together are moved and you get a clearer picture, then the theory is adjusted, or a new theory emerges altogether.

Theory Application
The Dreyfus Model of Skill Acquisition, which was first developed by Dreyfus and Dreyfus in 1980, is one way of looking at theory application. The model can be applied to the learning of any new skill; it suggests that those people who master specific skills must pass through five levels of proficiency in the process: novice, advanced beginner, competent, proficient and expert.

According to the Dreyfus Model, the novice is governed by rules and is unable to rely on previous experience to recognize relevant aspects within a situation. This person is like a new driver who starts and stops the car in a jerking fashion in an attempt to understand how much gas to give the car.

The learner in the next stage, advanced beginner, is still rule-focused, but has begun to rely on previous experience. This person will need guidelines in order to perform at an acceptable level.

Competent performers are more organized; they have a plan and have become more efficient.

Proficient performers are able to learn from previous experiences and can modify their responses in a given situation.

Experts, with their extensive experience and ability to see the significance and meaning within a contextual whole, are fluid and flexible in performing their skills. They are the chess player who develops a sixth sense for strategy, the athlete who develops a feel for the ball, the older child who rides as if his bicycle is an extension of himself, or the airline pilot who self-corrects during a difficult landing without having to think through each step of the process.

While Dreyfus applied this model to airline pilots and chess players, the model has also been applied by various nursing departments around the country to describe how caregivers advance from novice to expert clinicians. As a department, we believe that knowledge is gained, not just through theory and principles, but also through the embodiment of those principles in daily practice. Through the use of narratives or exemplars, one begins the process of sharing positive clinical experiences with others. As expert practitioners write about their practice, their stories demonstrate both sound knowledge and a highly developed sense of intuition. Experts "know" when a clinical situation is changing even when some common indicators may remain unchanged. Colleagues come to rely on these experts as teams of providers come together to provide care that is truly exemplary.

Link to: Clinical Recognition Program

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PATIENT-CARE DELIVERY MODEL
Our core values of patient-focused care and our belief that the patient/family-nurse relationship is essential, are critical to the development of our professional practice model. We also believe that these values are reflected in the way we deliver care every day.

The art and science of caring for patients includes a vast array of clinical and organizational activities, behaviors and processes. Much, but by no means all, of the context for this is provided by the patient-care delivery model, which is a detailed plan for an infrastructure to support the professional practice of caring for patients at MGH.

Link to: Nursing Units Index Page

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PHILOSOPHY
A philosophy statement is derived from the values, principles and beliefs that support the individualized work of each discipline. At MGH each clinical discipline is guided by its own philosophy which synthesizes the beliefs of its practice. Two examples of philosophies within Patient Care Services include:

Nursing
We believe that the essence of nursing practice is caring. Caring which is a science and an art deliverable, teachable, researchable, accomplished with wisdom, knowledge, compassion and competence.

We believe that the clinical practice of nursing is built on a scientific base evaluation of nursing practice is a professional responsibility critical thinking and scientific inquiry are essential to the improvement of practice.

We believe that we have the responsibility to educate ourselves and educate others expand our knowledge and expertise share this growing body of knowledge provide such opportunities to the greater healthcare community

Reading Disabilities
We believe that every language learning disabled individual deserves the right to be taught in the way he or she learns best.

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PRIVILEGES, CREDENTIALING, PEER REVIEW
Credentialing processes at MGH are designed to ensure that health professionals who provide services at MGH are qualified and prepared. The General Executive Committee has delegated this accountability to the Senior Vice President for Patient Care, Chief Nurse. Clinicians include:

• MGH employees who are registered nurses, registered nurses in the expanded role, physician assistants, physical therapists, occupational therapists, respiratory therapists, social workers, speech-language pathologists, pharmacists, dieticians, chaplains, and child-life specialists. Nurses in the expanded role include Nurse Practitioners (NPs), Certified Registered Nurse Anesthetists (CRNAs), Certified Nurse Midwives (CNMs)
  
  
• Non-MGH employees who are registered nurses providing services at MGH. These services include research, patient care, on-site review for managed care/payor organizations, facility screening for referral services, consultation.

Authorization Process for MGH Employees
For all candidates, the Human Resources Department and the respective manager/supervisor coordinate the application and selection process based on the candidate's education, proof of licensure/registration/ related certifications and experience required for the position.

Nurses in the expanded role and physician assistants, are also required by Massachusetts regulations to submit practice guidelines developed with their collaborating/supervising MD, NP-PA Application. A designee(s) of the Credentialing Steering Committee reviews the guidelines and makes recommendations regarding approval to the Senior Vice President for Nursing reviews these guidelines. The Senior Vice President signs the guidelines indicating approval, and a copy is sent to the clinician requesting authorization. This process is completed before the clinician begins practicing in the role.

Reauthorization for MGH Employees
Nurses in the expanded role are required to resubmit guidelines:

• at least every two years
• when the scope of practice changes or
• when the supervising physician changes

PAs are required to annually review prescriptive guidelines with their supervising physician per Massachusetts Regulations. PAs provide attestation (PA Attestation form) to The Credentialing Steering Committee that this process has been completed.

Authorization of Registered Nurses Who Are Not MGH Employees
Registered nurses who are not MGH employees but wish to provide services at MGH must complete and application (Non-MGH Registered Nurses Request for Authorization form) which indicates the professional activities they wish to perform, history of immunizations, and evidence of licensure and malpractice insurance. Authorization to do research, patient care, consultation is coordinated through The Norman Knight Nursing Center for Clinical & Professional Development. Authorization to screen patients for referral agencies or on-site review for managed care or payor organizations is coordinated through Case Management.

Link to: Clinical Recognition Program

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PROFESSIONAL DEVELOPMENT
As health professionals we place a high value on continuing professional development; we view it as essential to our ability to provide quality care, to achieve personal and professional satisfaction, and too advance our careers.

Link to: Clinical Recognition Program

Link to: The Norman Knight Nursing Center for Clinical & Professional Development Educational Calendar

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RESEARCH
The possession of a body of knowledge from research is the hallmark of a profession. Research is the bridge that translates academic knowledge and constructed theories into direct clinical practice. The challenge in the current era of health care is to generate knowledge that is clinically relevant and scientifically vigorous in order to contribute to the health care of the public. Therefore, the priority of healthcare professionals is to identify the major clinical phenomena of unique concern to their discipline and to develop substantial bodies of information in relation to these clinical phenomena.

Translating the questions generated at the bedside into formal scientific hypotheses is a part of the continuum of professional development. Research must become an integral aspect of clinical practice as healthcare professionals proceed from novice to expert. These research efforts define a systematic body of knowledge that guides professional clinical practice.

Healthcare professionals must weave experience as well as knowledge derived from research into their clinical practice. Application of research findings to clinical practice enhances the professional practice environment, and is critical to the improvement of patient outcomes. In the current era of change, there are unlimited opportunities available to nurses and health professionals to study and define the quality and cost-effectiveness of our professional clinical practice.

Link to: Yvonne L. Munn Center for Nursing Research

Link to: MGH Nursing Research Committee

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STANDARDS OF PRACTICE
Standards of practice exist to ensure that the highest quality of care is maintained regardless of the number of professionals providing care, or the experience of those professionals. Historically, standards of practice have consisted of a formal, chronologically detailed description of a particular practice or procedure along with a rationale supporting the activity.

In a professional practice model, standards of practice have supported the "learner", or novice/advanced beginner. For a provider lacking mastery, standards of practice provide a safe structure by which to practice, as they spell out what to do in situations where the provider has no prior experience, by breaking down the activity into elements and providing pertinent rules. They act as an essential teaching guide.

It is very important to understand that while serving the essential role of guiding the novice, standards of practice also guide the behavior of more experienced professionals. Standards of practice are the conduits of the institution's culture of care, and therefore, the very essence of that care. By serving as a teaching tool, they establish a level of expectation about care-delivery within an organization.

Universal adherence to standards of practice also provides an added measure of safety by extending the knowledge of clinical expertise when real experts may not be available. With the guidance of practice standards, clinicians can step into situations and perform effectively, even when more experienced providers are not present.

It is important to note that standards of practice are geared toward the "typical" situation and are not intended to supersede the individual, specific needs of the patient at any given time. Healthcare professionals face many complex situations every day. Understanding the unique clinical needs of each situation and the latitude in applying standards is imperative to providing effective, high-quality care. Strictly adhering to standards does not, in and of itself, constitute best care. It is up to the individual professional to recognize and interpret situations, and to know what standards of practice apply and in what ways they apply. The integration of clinical knowledge and standards of practice reflects a more proficient, or expert, professional.

Link to: Trove Policies and Procedures

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VALUES
Supporting our vision is a clearly articulated set of values which pervade our decision-making process and find daily expression in our policies, practices and norms of behavior. Our values combined with our vision provide both an affirmation of work which already exists and a foundation on which to bring about ideas not yet realized. Each of us makes decisions every day driven by personal and institutional values. The values we have chosen to be of primary importance to us as we move forward are: leadership, entrepreneurial teamwork, caring, innovation and scientific practice.

In addition, as described in our vision statement, we value accountability, responsibility, diversity, resource effectiveness and our core value-patient-focused care. During the course of the development of our professional practice model, our journey will be guided by these values and by a shared belief in our vision for the future.

Links to: Vision, Guiding Principles and Strategic Goals

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