Implementation challenges of a renal nursing professional practice model

Implementation challenges of a renal nursing professional practice model

Lori Harwood

Nursing care of an individual with end stage renal disease (ESRD) is complex, requiring increasing levels of clinical nursing and technical skills. In order to meet current and future practice and fiscal challenges in our facility, a renal nursing professional practice model (PPM) was developed. Numerous factors influenced the need for the PPM (see Table 1).

Specific details of the model and its development were described by Lawrence-Murphy et al. (2000). This is the only publication specific to renal nursing PPMs to date. The impetus for this paper is to share our unique experience of this endeavor and to promote the advancement of renal nursing practice.

In 1997, there was a corporate initiative toward articulating profession al nursing practice in the organization. Nursing leaders developed recommendations for professional nursing practice (Wong et al., 1997). In addition, the renal program was facing further fiscal restraint and the pending merger of two different hospitals. The team acknowledged the associated challenges and adapted the organization’s plan for professional nursing practice.

The London Health Sciences Centre (LHSC) is an academic teaching center that provides a wide range of programs and services to approximately 1.6 million people in Southwestern Ontario. The renal services provided are comprehensive and include: general ambulatory nephrology, care for patients with progressive renal insufficiency, three hospital hemodialysis (HD) units, seven regional community HD units, self-care and home HD, daily/nocturnal HD, peritoneal dialysis, and renal transplantation. An interdisciplinary team provides care across the continuum.

The PPM is a transformational model of care. It is utilized throughout the renal program in HD, peritoneal dialysis, and will be applied on the inpatient nephrology ward of one site when the renal program assumes leadership for this area in the future.

A renal professional practice steering committee of 24 individuals with representation from all sites was formed. Membership included: registered nurses (RN); nurse practitioners/clinical nurse specialists (NP/ CNS), the renal clinical educator, management personnel, and members of the Professional Practice Leader Nursing Team.

The process of PPM development took approximately 2 years from design to implementation. The PPM was implemented across all sites and in the regional community HD units. The definition of a PPM that guided the development of our model is:

A set of integrated beliefs, values, philosophy and vision which directs individual nurses in their practice and guides the organization in its relationship with nursing. It should include a shared decision making framework that provides and empowers nurses with increased opportunities for autonomy, accountability, responsibility, control over their clinical practice and collaboration (Zelauskas & Howe, 1992). A PPM is more than a care delivery system and includes a number of interrelated and critical elements that represent the principles, structural supports, and relationships central to the nursing practice system (Wong et al., 1997, p. 5).

Principles from the work of Benner (1984) as well as Wolf, Boland, and Aukerman (1994) were incorporated into the theoretical framework of our model. Concepts from case management and primary nursing were adapted to guide the nursing care delivery system. Consensus was reached regarding labeling the care delivery model as primary care nursing.

Our model consists of four components (see Figure 1): (a) professional practice, (b) characteristics of professional nursing practice (see Table 2), (c) process of provision of care, and (d) outcomes. The underlying belief is that nursing care contributes to and makes a significant difference in patient care outcomes (Lawrence-Murphy et al., 2000). The core of the PPM is the caring relationship between the nurse and the patient and family. Characteristics of professional renal nursing were identified (see Table 2), as were trends and future practice implications (see Table 3). National professional standards were examined. Consensus was reached on values central to professional development such as life long learning, competent patient-centered care, empowerment and accountability, and beliefs for care. Roles and competencies of the RN and NP/CNS were articulated. Nursing duties and non-nursing roles/duties were clarified. It was determined that nursing effectiveness would be strengthened by elimination of the following non-nursing work: tracking/ moving/stocking of supplies and equipment, portering functions, cleaning and set-up of dialysis machines, cleaning and moving of furniture, garbage removal, carrying dialysate to each machine, basic clerical functions, handing out patient lunches, and ordering supplies. The role of the nurse changed to account ability-based practice with a consistent vision and clear expectations regarding the role of the primary nurse (see Table 4).

[FIGURE 1 OMITTED]

Model Implementation

Members of the steering commit tee agreed that the key to successful implementation of the model was ongoing communication with the nursing staff throughout the entire process. The first strategy employed to communicate with staff was a newly formed Nephrology Nursing Network Newsletter ([N.sup.4]). The first issue presented the development of the PPM project and listed the members of the committee. In addition to the [N.sup.4], committee members disseminated information to and solicited feedback from the nursing staff throughout the development process. A template outlining strategies for implementation was created to introduce the draft document to the nursing staff and other key stakeholders. Although the PPM is a nursing model, nursing does not function in isolation. Therefore, feedback from patients, physicians, and allied health colleagues was sought and incorporated into the model.

Marketing strategies included providing a large colored poster at each site depicting key elements of the model and a second edition of the [N.sup.4]. This was followed by introductory sessions entitled Creating our Future: Advancing Professional Nursing Practice in the Renal Program, which were attended by approximately 95% of the nursing staff. The primary intent of the sessions was to present elements of the model in a realistic, clinically relevant fashion without devaluing current clinical practice. A secondary intent was to provide a forum for staff to network with colleagues from all sites. The model was presented through a case scenario with role-playing. This strategy facilitated presentation of the concepts of the current care delivery model and those of the proposed new model. The goal was to provide staff with a concrete illustration of the differences between the models. Once the role play was presented, small and large group discussions took place. The staff were able to identify barriers and challenges for effective implementation as well as to provide feedback on the model content.

The next challenge was to successfully implement the model into clinical practice, remaining cognizant of the challenges and barriers identified. A task team consisting of members from the steering committee facilitated model implementation across all sites. The first step for this group was to review feedback, incorporate changes, and refine the model. The next step was to conduct a professional development needs assessment for nursing staff. Analysis of these results assisted the task group in identifying strategies and determining where and how to direct resources. Five serf learning education modules pertaining to renal nursing (anemia management, renal bone disease, physical assessment, critiquing research, assessment and management of diabetic foot complications) were developed by the NPs/CNSs to help meet the educational needs. The group also developed a Primary Nursing Responsibility Checklist to facilitate the organization of work according to the model expectations. The third step was to provide information on the model and changes in nursing care delivery to non renal services within and external to the organization (i.e., community care providers).

A resource binder was developed and distributed to each nurse in the program around the launch date. Contents included: (a) the model; (b) copies of letters sent to patients and members of the multidisciplinary team; (c) a final [N.sup.4] newsletter that highlighted survey results, future activities, and a proposed evaluation for mat; (d) a copy of the primary RN responsibility checklist; mid (e) draft guidelines for assigning new patients to primary nurses. An additional benefit to this resource binder was that it could serve as the basis for a reflective portfolio mandated by the provincial nursing licensing body. The binder is also useful in preparing for and maintaining national nephrology nursing certification.

Following the launch, unit specific sessions were conducted to further highlight elements of and expectations for practice according to the model. The members of the steering committee were available for ongoing support and coaching. A Nursing Professional Practice Committee was established with the mandate of planning for future modifications and maintaining momentum gained with changes to clinical practice. A summary of strategies adopted during the implementation is listed in Table 5.

Implementation Challenges

The challenges inherent when taking on a task of this magnitude were augmented by: (a) the time and energy required for maintenance of the model; (b) the external environment, specifically the concurrent city-wide program merger that resulted in the moving and mixing of hundreds of staff and patients; and (c) program issues including the opening of a new HD unit, a vacant program manager position, documentation issues, and changes in position descriptions.

Time and energy–an observation. Shortly after the implementation, it became apparent to the development team members that implementation of the PPM would require significantly greater amounts of both clinical and managerial nursing leadership time than had been anticipated. Many other issues were occurring during the PPM planning and implementation, both internal and external to the program, that diverted time and attention. Despite a well-executed educational effort, there continued to be knowledge deficits and misperceptions among nurses about the model. Some nurses viewed primary nursing as duties in addition to their current workload as opposed to a different model of practice, and were reluctant to carry their own caseload on a long-term basis. Many nurses expressed the concern that being a primary nurse would result in less time at the bedside with patients. According to our Professional Practice Leader for Nursing (Wang, personal communication, April 2002), this model does not require a greater knowledge base or more accountability of the professional nurse than other PPMs. However, the model provides more continuity of care over time enabling the professional nurse to detect subtle changes that may go unnoticed with more episodic models of care.

External Environment

Mergers and moves. The largest factor that resulted in competing priorities for time and energy was the merger of the two London Renal Programs into one program and the move of one site to a new larger HD unit. This was all consuming. New working groups including nurses, management, physicians, allied health, and support staff were established. Differences in beliefs, values, and practices among the providers surfaced. Patients worries and questions regarding dialysis schedule, new caregivers and locations, considering both clinical issues and patient preference, needed to be addressed.

Staff were also concerned about their future: Who would they be working with? Where? What did this mean for seniority? Would they be working with peers, physicians, and patients who they had grown to appreciate and respect? Support was often needed to allow for grieving and closure.

All sites were impacted by this merger/move. The preparation for the merger and move occurred shortly after the implementation of the PPM and primary nursing, and required complete attention of managerial and clinical nursing leadership as well as other health disciplines.

Within this, merger policies and procedures had to be consistent and evidence based. A small task force was charged with reviewing all protocols and procedures with the purpose of choosing best practice or combining practice elements based on current evidence to create program-wide policies and procedures. Procedures and protocols were reviewed by multidisciplinary team members, such as pharmacists and dieticians, when appropriate. Members of the professional practice committee played a key role in facilitating group consensus on changes. Once policies and procedures were developed, staff education was provided, and references were placed in central unit areas for easy future access. This process also took longer than expected. It became apparent early on that all procedures had not yet been revised. This further polarized the merged nursing staff, as each group functioned with different procedures reverting to the practice that was most familiar to them.

Operational review. During the PPM development phase and early implementation, the corporation was going through its own turmoil. Several years of operating deficits had resulted in a financial and then operational review. The operational reviewers recommended that the charge/resource nurse and coordinator (first level manager) positions in the patient care systems division be collapsed into one position. Consequently, the charge nurse positions were filled in a temporary, rotating capacity by staff nurse volunteers until the results of a role review could be completed.

The lack of consistency in this leadership role was detrimental to the implementation of the PPM. It was difficult for the rotating charge nurse to monitor the primary patient/nurse assignment. If a nurse was struggling with PPM implementation, the acting charge nurse did not feel comfortable intervening and lacked perceived authority as she/he would once again be working in a peer capacity. The constant change in leadership required attention to be directed to more immediate issues, consequently PPM implementation became a lower priority. At this writing, the charge nurse role has been filled on a temporary full time basis until the results of the hospital wide role and salary review will soon be completed.

Program Issues

Leadership changes. Approximately 1 year after the initial implementation, the Renal Program manager resigned, followed 6 months later by the clinical educator. Without the clinical educator and managerial leadership to champion this model, other competing priorities intervened. The clinical educator position was filled quickly, but the new incumbent did not have extensive background in the development of the model, and her priorities were to address nursing best practice and standardization of processes related to the merger.

The program manager position was vacant for 7 months, and the initial priorities of the new manager did not include PPM implementation. The new manager, who has had experience with practice models at staff nurse and managerial levels, is committed to the successful implementation of the model.

Documentation issues. New documentation tools, such as a HD treatment record, were necessary to ensure continuity of care across the program. Subtle differences in systems across sites increased the complexity of providing consistent documentation tools in a timely manner. In retrospect, it was apparent that this process should have been started earlier. Still, consistency with documentation increased comfort levels during relocation of staff and patients. Work also began on a new patient care profile and patient assessment record under the direction of the documentation committee. As part of the model, a primary nursing checklist of responsibilities was developed. Some nurses misconstrued the purpose of the checklist, believing it to be performance appraisal as opposed to a care delivery tool.

Evaluation

To elicit evaluative information on the PPM, nurses in all 10 HD units, physicians, and allied health personnel were surveyed via questionnaire 6 months post-implementation. The open-ended questions elicited information of staffs perceptions regarding the operationalization of primary nursing and its impact on patient outcomes. The questions were worded to procure information on systems management issues, such as effectiveness of documentation tools and the process of assigning new patients to primary nurses. The response rate was 50% (n=91). The focus of this discussion is on the information obtained from the nurses as it provides the most enlightening information in terms of perceptions of the model and the implementation.

The intent of qualitative research is to elicit information that describes, an experience and to discover common meanings that underlie variations in a given phenomenon. Using the tools of language, similar phrases and terms can be linked and themes extrapolated. Responses to open-ended questions are rich with information reflecting not only content, but attitude and emotion. The authors endeavored to interpret nurses responses and pare ideas into themes that described their experience with the implementation of this model into their practice.

It is obvious from nurses responses that, ha theory, they are interested in and have varying degrees of commitment to professional practice and primary nursing. It appears, however, that interest has not translated into commitment for a variety of reasons. The theory practice gap is an evident barrier to implementation. Themes supportive of this include: time, standards of practice/care, and accountability.

Time: “Our time is totally taken up by the assignment we are given–on/off procedures, medications, dressings, problems with patients, machines or other equipment, short staffed, ICU/CCU, new patients, etc.”

“When I have the time I know my patients are better off [with a primary nurse] as someone makes sure little things don’t fall through the cracks, therefore increased patient satisfaction and nurse satisfaction.”

“The use of nurses time is good because it makes each nurse accountable to their patient and family, physicians, peers, etc.”

This theme is multidimensional in that time was a term used repeatedly to describe frustrations associated with nurse-patient ratios, high patient acuity, and clinical tasks inherent to the care of patients undergoing a technological intervention (HD).

Standards of practice/care–accountability: “As much as I can, I’ve been able to carry out the functions of the role, if and when I want to. But why should I put in more effort when the rest get away with doing less.”

“More guilt at not doing enough.”

“I recommend that you let me walk the walk, not just your talk.”

Once again, frustration was evident in nurses’ responses. It appears that nurses intrinsically aspire to perform at the highest standard However, there were negative overtones that depicted the hegemony between accountability and performance rewards. The nurses were not only frustrated with the inability to meet the standards articulated in the model, but were uneasy with lack of consequences associated with performance below the standard. They described a need for methods of dealing with performance issues from both the administrative and peer levels. Resolution of this issue would promote reduction of the theory practice gap.

Many authors have discussed the theory-practice gap as a reality in nursing. For the most part, it is described in the context of the student learning the theory and skills of nursing in a classroom setting, with subsequent application in the clinical setting (Benner, 1984; Knight, Moule, & Desbottes, 2000; Rolfe, 1996; Ward & McCormack, 2000). However, the theory-practice gap was evident among experienced nephrology nurses during the implementation of the PPM. Conflicts and contradictions between policy and practice can complicate the work environment. This turbulence can give rise to a series of disjunctions and tensions between professional, administrative, and practical interests (Stark, Cooke, & Stronach, 2000). Certainly anecdotes from nurses described such a phenomenon, in that there perceived to be a lack of consequence if the standards articulated in the PPM were not met.

The responses from surveyed participants also reinforced concerns that nursing practice had reverted back to patterns present before model implementation, causing one to question if a new manner of practice had ever been realized. In a time of severe budgetary constraints, all health care providers can relate to a sense of frustration in providing comprehensive care with dwindling resources. It appears that a model intended to empower nurses at the bedside has, perhaps, negatively highlighted this sense of inadequacy. On a more positive note, the flavor of the anecdotal information from allied health personnel, nurse practitioners, and physicians indicated that they view primary nursing as having the potential to positively impact and improve upon the quality of care provided to our patients. This, coupled with the theme of nurses aspiring to a high standard of practice is incentive to persist in overcoming barriers and making this a model of care a sustainable reality.

Discussion

Hoffart and Woods (1996) defined a professional practice model as a system containing structure, process, and values that support practice within the nursing care delivery environment. A PPM contains five subsystems: values, professional relationships, a patient care delivery model, a management approach, and compensation and rewards mechanisms. Evaluation to date of our PPM provided evidence for positive outcomes however, integration into individual nurses practice remains variable, not universal as intended with the model. Upon reflection, the authors question if we have developed and implemented a thorough care delivery model juxtaposed to a PPM.

Our PPM was based on the work by Wolf, Boland, and Aukerman (1994) (see Figure 1). This is a transformational model and focuses on values and relationships in actualizing the outcomes (Hoffart & Woods, 1996). However, analysis of oar PPM as per Hoffart and Woods (1996) criteria reveals that not all five subsystems were incorporated. Specifically, our PPM does not address compensation and rewards subsystems. Qualitative evaluation of the model revealed some negative nursing practices of purposefully not engaging in professional practice and primary nursing due to lack of both extrinsic motivating/reward factors and consequences for unsatisfactory practice.

This raises the issue of responsibility, accountability, and power. Accountability without power leads to frustration and failure (Hoffart & Woods, 1996, p.361). Kanter (1993) defined power as the ability to get things done, to mobilize resources, to get and use whatever one requires to achieve his/her goals. Laschinger (1996) noted a relationship between staff nurse empowerment and increased self-efficacy, motivation, organizational commitment, autonomy, and leader empowering behaviors. Sadly, research indicates that generally nurses are not highly empowered (Chandler 1991; Laschinger 1996). It has been proposed that powerlessness in nursing staff results from the sense that they do not have positional power in the acute care setting (Chandler, 1991). Empowerment involves enabling behavior and a sharing of power (Kanter, 1993). While discussions regarding decision making processes and shared governance occurred at the steering committee level, changes in decision-making processes were not clearly articulated. Staff nurses participated in the revision/creation of documentation tools and policies and procedures. However, their comments and the absence of changes ha decision-making patterns indicate that this was insufficient. Still, the onus for this problem does not lie solely with management. As power is taken, not given (McWilliam, personal communication, September 1992), a certain amount of the responsibility lies with the nurses. This notion is supported by Clifford (1992) who considered empowerment a process that begins at the grass roots and is facilitated by management. Perhaps the NPs/CNSs need to assume a more active mentoring role in assisting the nurses not only in making patient care decisions, but in changing unit systems that promote bedside decision making processes and shared governance.

In addition to overall nursing practice, it is important to remember that individual reflection and evaluation is an important component of professional practice. Nursing leaders in the organization have developed a hospital wide performance appraisal tool for nurses. As with the PPM, the renal program has taken the template and begun revising it to make it renal specific.

All nephrology nurses are expected to be change agents and leaders in upholding the values and practice of the model. However, no one person in the renal program was identified as an authority on professional practice models; nor was anyone charged to continue the vision and momentum on a broader level since the implementation. Professional practice leaders have not been involved since the development of the project, and the steering committee was replaced by the professional practice committee. Perhaps ad hoc continuation of the steering committee post implementation would have been of benefit. Issues requiting reinforcement of the elements of the model and problems arising from the care delivery system are continuous and evolving. The renal professional practice committee was given the mandate to oversee and promote professional nursing practice within the renal program. Enormous amounts of work have been produced from this committee; however, with the merger of two different organizations and multiple nephrology sites, the committee has been focusing on the day-to-day practice issues. Evaluation of the model and programmatic reflection has been overshadowed.

Economic analysis of our PPM is beyond the scope of this article; how ever, significant costs were associated with the development and implementation of the model in regards to human resources. Equally important are the human resources required for evaluation and maintenance of the model. Such factors need to be taken into consideration when entering an endeavor such as this.

Evaluation and measurement of outcomes associated with PPMs are difficult, as the impact of professional practice is more than a cause and effect relationship. Ingersoll et al. (1995) noted that extraneous events and environmental changes can influence the outcomes being measured. They advised including methods to account for such confounding variables. Despite this complexity, simple evaluations can be done. Surveys can be conducted among patients and staff to assess their satisfaction and attitudes regarding the model. Chart audits could also be done. For example, if it is the expectation that monthly medication reviews he done with patient, a simple comparison between the medication record and what medication the patient is actually taking can be made. A program-wide Quality Council has been established. However, PPM outcome measures have not yet been integrated into the CQI process. Objectives of the PPM were agreed upon; however, these did not translate into directly measurable outcomes. Our experience is not unique, as long-term evaluations of the impact of PPMs on nursing practice, organization, and patient outcomes are lacking, and published evaluation reports from these and other PPMs are not common (Hoffart & Woods, 1996).

Evaluations of PPMs are complex and difficult. Still the process must be addressed during the developmental stages complete with an action plan, time line, and potential pre- and post-intervention methodology.

Lessons Learned

Three primary lessons were learned. First, there clearly needed to be a plan for model maintenance and evaluation, including mechanisms for performance feedback and appraisal, at the outset. It would have been advantageous to have included this throughout the process of model development as opposed to addressing it toward the end. Second, it is critical to carefully consider timing when undertaking a task of this magnitude. A tremendous amount of energy was redirected from model implementation to adapting to the multiple changes associated with the merger (new units, new staff, new patients, new policies, new unit cultures, and a new front line manager). Third, we learned that the model is, in fact, valued. Unfortunately, as a program, we continue to struggle with commitment to and translation of the concepts into practice. Through the qualitative evaluation, we began to understand the barriers to model implementation as perceived by the nurses.

The above initiatives were program-wide in nature. Consistent goals, policies, and procedures were necessary. However, it is important to recognize that each site has its own unique culture, hence challenges in implementation. These challenges continue to be addressed within the specific units.

Future Directions

The philosophy and premise of the model are now supported by both front line nursing and program administrators. A key element in the model moving forward is the presence of a manager committed to ensuring there is an infrastructure in place that will promote quality care. Since the manager position was filled, the job description for the (primary) nephrology nurse has been formalized. Generation of a nephrology nurse performance appraisal tool is in process. This is a move toward addressing concerns regarding accountability in practice. The team is also looking at reward mechanisms for stellar performance. An education fund has been established at each site with the mandate of supporting nurses in attending conferences and workshops.

All sites will be encouraged to develop and document exemplars that describe significant interventions made possible because of the PPM. It is important to collect data to document how primary nursing makes a difference. The accounts of how primary nursing makes a difference will be documented by various team members. Such data will play a role in promoting this model of practice within our program with the aim of validating the importance of having professional nurses care for dialysis patients. We believe that once nurses see the difference they make in patient care, the dissatisfaction and accompanying burnout that results from feelings of disempowerment will diminish.

In the Canadian health care system, there is little opportunity to financially reward staff who have been star performers, as merit pay has not been accepted or utilized. Managers can, however, recognize staff in other ways, such as acknowledging a job well done and seeking their opinions on future initiatives and interesting projects. Managers can also provide educational support for star performers. These strategies will be utilized in a more deliberate manner to support nurses who successfully work within and promote the PPM.

Communication between the primary nurses and the team has been identified as a barrier. Several initiatives have been implemented in order to overcome this. Primary Nurse Kardex Rounds have been instituted at two of the sites. Although this process is still in its infancy, the plan is to promote its development at all sites. Electronic mail access has been initiated for all nurses in the program that has facilitated communication.

Summary

Implementation strategies for our PPM were innovative, enthusiastic, and well planned. Since the implementation, we have experienced a slight decline in the momentum of the model It is clear that the resources and effort required for model maintenance are equal to those invested in the development and implementation. The professional practice committee and nursing leadership team continues to work towards advancing practice while maintaining the tenants of the model. As noted, some momentum had been lost. Initial model evaluation has revealed key areas to be addressed, specifically the theory-practice gap and staff nurse empowerment. As the nephrology population continues to increase, new programmatic priorities emerge. The issue of providing quality care remains at the forefront, and one method of accomplishing this is to hold true to the renal nursing professional practice model.

Table 1

Factors Influencing the Need for a PPM

* Enhance continuity of care delivery

* Care delivery in an environment of constrained resource

* Administrative and organizational initiatives

* Upcoming merger of two acute care renal programs on many sites

* Consistency with nursing practice and determination of best practice

* Changing environments with the opening of one new acute care

hemodialysis unit

* Planning for ongoing development of renal nursing practice

* Articulate the professional nursing role and the contributions

to patient/family outcomes

Table 2

Characteristics of Professional Nursing Practice

* Autonomous decision making

* Accountability in planning, coordinating, and intervening

in the provision of care

* Effective communication and collaboration among health care providers

* Continuity of care between providers and between settings

* Conscientious application of critical thinking and evidence-based

decision making

* Engagement in reflective practice and ongoing education

* Fiscally responsible practice

* Practice according to professional standards and ethical principles

* Demonstration of values and respect for individuals and their right

to make choices

Table 3

Future Trends

* Increased growth in program

* Increased focus on secondary

prevention

* Advancing technology

* Increased sophistication of the

health care consumer

* Ethical issues

* Outcome-based care delivery

* Introduction of new roles

Table 4

Clarification of Nursing Roles

Accountability-Based Model of Care Delivery

Accountability of all nurses at each treatment

(episode of care):

* Complete a pre-dialysis assessment of the patient and

document the results.

* Obtain lab specimens as ordered,

* Monitor vital signs hourly or as required.

* Perform direct patient care activities as required [e.g.

dressings, blood glucose] and assist with exercise program

as needed.

* Update any changes that are needed on the care plan

that result from that specific treatment.

* Obtain results of that treatment s blood work (if required,

e.g. INR) and contact appropriate health team member

(re: these results).

* Process any physician s orders.

* Implement nursing interventions in response to changing

situations and monitor the outcomes of the interventions.

* Update health history and medication list as required

(i.e. if patient has been recently discharged).

* Obtain orders for any changes as needed (e.g. change in

ideal weight) and document clearly.

* Review and reinforce teaching plan as indicated by the

plan of care or specific needs of that treatment (includes

assessment of learning needs & responses). Document

need for follow-up.

* Review any unseen blood work and report any concerns

to the appropriate team member. Complete any documentation

for UKM, etc.

* Ensure treatment plan and patient care profile are up-to-date

with any changes, etc.

* Make or request referrals as appropriate, documenting

clearly so follow-up is achieved.

* Notify the nurse in charge of any change in patient condition.

* Relay any pertinent information to the nursing unit, home

care, family, or nursing home as required.

* Communicate with Primary Nurse as necessary.

* Order/dispense/administer medications as needed.

* Complete any other documentation records as required

(e.g. next treatment record, Assessment & Intervention

flowsheet).

* Initiate the initial nursing assessment/history sheet and

orientation to the unit, if patient s first treatment.

* Operate the hemodialysis/peritoneal machine within

safety limits and unit protocols, including solving alarm

situations (i.e. troubleshooting).

Accountability of the Primary Nurse RN

(across episodes of care) for certain assigned patients:

* Develop a care plan, including assisting the patient and

family to set goals (short and long term) in order to

achieve optimal health.

* Assess learning needs and develop an initial teaching

plan.

* Coordinate care within the treatment setting.

* Ensure that the initial health history/assessment is completed.

* Develop a therapeutic relationship with the patient and/or

family.

* Liaise with nursing unit if patient admitted or transferred

to satellite unit.

Monthly:

* Review medication list providing teaching as necessary,

investigate any discrepancies and obtain orders as

required.

* Review trends in lab values and/or results of tests that

have a need for long-term follow-up.

* Consult/inform other health team members as necessary.

* Review and update health history as needed.

* Review plan of care with patient/family re: goals and their

achievability, any concerns, or questions.

* Refer to appropriate team member, if necessary.

* Ensure that the plan of care is current, documented

clearly, and reflects the goals of the patient and/or family.

Table 5

Summary of Implementation Strategies

* Resource binders to all staff with a copy of the PPM and serve

as a reflective practice portfolio

* The model and illustrations were in all units

* Self-directed learning modules were developed to enhance core

knowledge

* Champions of model on each site to provide ongoing encouragement

and education

* Formal and informal rounds on the model and updates

* Assignment of staff to primary patients and families

* Positive feedback from management

* Newsletter

* Acknowledging adjustment time need for change

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Zelauskas, B., & Howes. D.G. (1992). The effects of implementing a PPM. Journal of Nursing Administration, 22(7/8), 18-23.

Lori Harwood, MSc, RN CNeph(C), is an Acute Core Nurse Practitioner/Clinical Nurse Specialist in the renal program, Victoria Campus at the London Health Sciences Centre, London, Ontario. Ms. Harwood is a member of the North Central Chapter of ANNA.

Julie Ann Lawrence-Murphy MScN, RN(EC), CNeph(C), is an Acute Care Nurse Practitioner/ Clinical Nurse Specialist in the renal program, University Campus at the London Health Sciences Centre, London, Ontario.

Jane Ridley, MScN, RN, CNeph(C), is an Acute Care Nurse Practitioner/Clinical Nurse Specialist in the renal program, University Campus at the London Health Sciences Centre, London, Ontario. Ms. Ridley is a member of the North Central Chapter of ANNA.

Phyllis Malek, BHScN, RN, CNeph(C), is an RN in the Adam Linton Hemodialysis Unit, Victoria Campus al the London Health Sciences Centre, London, Ontario. Ms. Malek is a member of the North Central Chapter of ANNA.

Lorraine Boyle, BScN, BSc, RN, is currently enrolled in the Masters of Business Administration program at McMaster University, Hamilton, Ontario. At the time of implementation of the Professional Practice Model, Mr. Boyle was the Clinical Educator in the renal program at the London Health Sciences Centre, London, Ontario.

Sharon White, MBA, BScN, RN, is currently the Manager of Renal Care for the renal program at the London Health Sciences Centre, London, Ontario.

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