IDEAS IN LEADERSHIP 63 Describing the Essential Elements of a Professional Practice Structure Sue Mathews, BA, MHScN Chief of Nursing and Professional Practice Southlake Regional Health Centre, Newmarket, Ontario Past President, Professional Practice Network of Ontario Sara Lankshear, RN, BScN, MEd Principal Consultant Releve Consulting Services Burlington, Ontario President-Elect, Professional Practice Network of Ontario Abstract The proliferation of program management, coupled with the introduction of the Regulated Health Professions Act, prompted many healthcare organizations in Ontario to introduce professional practice models. In addition, the Magnet Hospitals research (Kramer and Schmalenberg 1988) identified the existence of a professional practice model as a key element for recruitment and retention of professional staff. Professional practice models were introduced to address issues of accountability, identity and overlapping scopes of practice as experienced by healthcare professionals and organizations across the continuum of care. The authors of this paper describe exploratory work done through the Professional Practice Network of Ontario to identify the essential elements of the ideal professional practice structure, key areas of challenge and strategies for adapting these elements into an organization. The paper presents a list of 16 essential elements of an ideal professional practice structure with a further discussion on four key areas consistently identified as areas of challenge. This paper is intended to report, not the findings of a formal research study, but rather the result of facilitated dialogue among professional practice leaders in Ontario. The information will be of interest to healthcare organizations across the continuum of care and to professional associations and academic institutions, as we all address the challenges of creating a quality work environment that supports and fosters excellence in professional practice.
64 Nursing Leadership Volume 16 Number 2 Introduction The proliferation of program management, coupled with the introduction of the Regulated Health Professions Act, prompted healthcare organizations in Ontario to implement professional practice models. In addition, the Magnet Hospitals research (Kramer and Schmalenberg 1988) identifies the presence of a professional practice model as a key element for recruitment and retention of professional staff. Professional practice models were introduced to address issues of accountability, role clarity and overlapping scopes of practice as experienced by healthcare professionals and organizations across the continuum of care. However, these models have been adopted to varying degrees. Some facilities have completely redesigned their organizational structures, as evidenced by the presence of professional practice portfolios complete with the introduction of professional practice roles, while others have worked toward a cultural shift without specific operational support (e.g., specific FTE allocations). Despite these differences, those in roles responsible for professional practice within healthcare organizations are dealing with similar issues: scope of practice, interdisciplinary practice, client-centred care, care delivery models, credentialing and certification processes and, ultimately, quality of work life. As professional practice roles have evolved, it has become clear to those in leadership positions that there is a need for networking, information sharing and mentoring. Professional Practice Network of Ontario The Professional Practice Network of Ontario (PPNO) was established in 1999 as a result of an informal conversation between two nurse leaders in professional practice roles who had a desire to connect with colleagues in similar roles and share information. The PPNO quickly grew to include membership of over 25 organizations across Ontario, including professional practice leaders from staff line to senior management positions; a variety of professions (e.g., speech language pathology, social work); and the various healthcare sectors (e.g., acute care, long-term care, rehabilitation and community environments). The purpose of the PPNO is to provide an interprofessional forum for communication and collaboration among leaders in professional practice, to promote new knowledge in professional practice and to promote excellence in professional practice. In response to tremendous growth, in 2002 the PPNO made the transition from an informal group of colleagues to an incorporated body complete with by laws and an executive board. The PPNO meets quarterly, facilitating in-depth dialogue on topics relating to professional practice. Identifying the Essential Elements for Professional Practice Structures Through networking within the PPNO, members recognized that although we
Describing the Essential Elements of a Professional Practice Structure 65 were individually dealing with similar issues, we were addressing them in many different ways. The diverse backgrounds and levels of expertise among members (e.g., some were new to their roles while others were more established) also provided a great amount of experiential knowledge from which we all benefited. This sharing led to a facilitated discussion of the following question: Knowing what you know now, if you could create the ideal professional practice structure for your organization, what would be the key elements to include? Common themes from small group discussions generated the following list of 16 essential elements : 1. Formal communication lines (consultation prior to decision-making) 2. Well-established linkages within the organization 3. Council structures in place (strategically and unit-based) 4. Clearly defined authority regarding professional practice related issues 5. Purpose with a corporate/strategic view 6. Interprofessional nature 7. Client-centredness 8. Supports in place to assist in changing the culture 9. Senior administrative support and linkages 10. Flexible, non-silo approach (across all programs) 11. Multidisciplinary roles (beyond nursing) 12. Collaborative practice principles 13. Promotion of staff competency 14. Clear linkage to organizational mission and vision 15. Linkage with physician (MAC) 16. Consideration of context of practice setting (workplace environment) Figure 1 expands the list with descriptors. FIGURE 1: Description of essential elements for professional practice models (as determined by PPNO members) Essential Element Description 1. Formal communication lines Clearly defined formal communication lines regarding expectations for consultation and collaboration to ensure all stakeholders are involved in decision-making 2. Well-established linkages within the organization 3. Council structures in place 4. Clearly defined authority Professional practice roles and structures that are effectively linked in order to maintain effective communication (e.g., such areas as human resources, programs, organizational development) Specific structures in place to address professional practice issues, structures that exist at a strategic level and a unit- or profession-specific level Areas of authority and accountability clearly defined, and that may include such areas as credentialing, hiring, input into skill mix/staffing ratios, professional development requirements
66 Nursing Leadership Volume 16 Number 2 Essential Element 5. Purpose with a corporate/strategic view 6. Interprofessional nature: structure and roles 7. Client-centredness 8. Supports in place to assist with changing the culture 9. Senior administrative support and linkages 10. Flexible, non-silo approach 11. Multidisciplinary roles 12. Collaborative practice principles 13. Promotion of staff competency 14. Clear linkage to organizational mission and vision 15. Linkage with physician/mac 16. Consideration of context of practice setting/work environment Description Professional practice roles and structures that maintain a macro and a micro perspective (e.g., ability to link initiatives to professional and organizational levels); ability to roll information continuously up and down the organization Structure that reflects all regulated and non regulated professions within the organization Although the primary customers of professional practice structures are the clinicians, the linkages between practice and client care/organizational outcomes are recognized Going beyond training and education to address mental models, assumptions and mores within the organization Clearly defined linkages to senior management through indirect or direct reporting relationships Ability to analyze and address issues that have an impact across programs, services and professions; ability to see big picture regarding professional practice internal and external to the organization Specific FTE allocations for roles/positions; positions reflect multidisciplinary teams (e.g., roles for professions other than nursing) Looking at issues that may be profession-specific and interprofessional in nature; established partnerships between professional practice areas and programs/services Proactive initiatives to ensure ongoing competency; keeping an eye on the horizon for external impacts on practice; going beyond just training Purposes for professional practice roles and structures that are clearly linked to the overall corporate mission and vision and corporate scorecard indicators. Well-established linkages with MAC; professional practice leader/appointment to MAC; active MAC representation on interprofessional groups Recognition of the impact of practice setting on the ability of professionals to meet client needs/outcomes; specific accountability to look at quality of work life from the perspective of the clinician (e.g., ability to meet standards of practice, quality assurance requirements) Members were asked to assess their current professional practice structure according to these essential elements. For each element, individuals then identified a point along the continuum (Got it > Getting there > Not in place) that best reflected their current structure. Figure 2 shows the result of this selfassessment exercise. Overall, the picture shows structures at various points of growth and transformation, with the vast majority of the essential elements in place to some degree and few organizations viewing themselves as having the ideal structure.
Describing the Essential Elements of a Professional Practice Structure 67 FIGURE 2: Essential elements for professional practice structures: self-assessment results 16 14 12 10 8 6 4 2 0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 Not even close Getting there Got it! The Four Key Areas of Challenge Of the 16 essential elements, four came forward consistently as the most challenging issues for professional practice leaders. Each issue was then discussed in more detail to develop a sense of why these areas pose such a challenge and to identify effective strategies to address them. Organizations that assessed themselves as having gotten it shared their strategies for successfully incorporating these elements into their structures. The four areas of challenge identified were: 1. Formal communication and clear authority (combined because of the similar nature of the elements) 2. Support to change culture 3. Flexible, non-silo approach 4. Strong physician linkages Formal Communication and Clear Authority Challenges Identified Although professional practice roles, departments and portfolios are seen as accountable for promoting professional practice in the workplace creating an environment that supports clinicians to incorporate evidence-based practice, maintain their competency and/or create systems and processes to enhance practice and professional development very few have clear direct authority relating to these areas. The primary customer of professional practice structures and roles is the clinician (primarily, regulated professionals), yet the formal authority regarding clinicians and services (e.g., FTE allocation, skill mix, service delivery models, performance management) resides in the operational areas of the programs or departments. Although clinical management and professional leadership are often viewed as being totally independent from each other, the challenge remains to distinguish between the two (Comack et al. 1997). The extent of active involvement or consultation between professional practice and programs often depends on the culture of the organization and the relationships among colleagues.
68 Nursing Leadership Volume 16 Number 2 Strategies Shared 1. Incorporation of the principles of shared governance and continuous quality improvement (CQI) into the decision-making framework of the organization. Shared governance (Porter-O Grady 1998) emphasizes the importance of professionals being accountable for professional practice, while managers are accountable for creating a work environment that supports the practice and, ultimately, client care and outcomes. CQI processes emphasize the need to identify key stakeholders and determine mechanisms for involving them in the planning and implementation of projects. 2. Clearly defined expectations and processes to support consultation and collaboration between professional practice and programs/services regarding program planning or service development changes that may have an impact on skill mix, staffing patterns, delivery of care models, skill set requirements, credentialing and/or scope of practice (e.g., controlled acts). 3. Clearly identified corporate accountability for professional practice. Differentiate between the individual accountability of all clinicians for their practice and ongoing competency and the overall accountability in the organization for systems and processes required in order to create a quality work environment that supports professional practice. Support to Change Culture Challenges Identified The restructuring initiatives of the 1990s resulted in mergers of various organizations with very distinct cultures and perspectives. The merging of organizations resulted in the merging of practices and challenging of assumptions of what was best practice and how this was being defined. Adding to this challenge is the fact that the construct of professional practice is not well defined or understood. Professional practice holds a variety of meanings often determined by the lived experiences of key stakeholders and the culture of the organization. All too often, practice needs were viewed solely as training needs. Professional practice leaders were struggling to move beyond the they need an in-service approach to ongoing professional development and developing an awareness and appreciation of the affective domain of learning (values, feelings and assumptions), not just the cognitive and psychomotor domains. Creating an environment of reflective practitioners requires that time be spent on addressing mental models and assumptions. Reflection on practice is necessary if professionals are to function in the complex and nonroutine situations in which they find themselves (Williams 2001). Without such reflection, individuals assumptions may continue to stand in the way of learning and adapting to change. Strategies Shared 1. Dedicated organizational resources to support creating and sustaining the cul-
Heart of the City tural shift required to support a professional practice environment. Resources to include dedicated time/allocation of FTEs for professional practice roles, support for staff to attend professional practice meetings, and mechanisms for connecting with external organizations, colleagues and groups or agencies in order to have access to the best available information and evidence. 2. A clear shared vision for professional practice within the organization, including what it means to professionals and ultimately how it benefits client care. This shared vision should also reflect and be consistent with the organizational mission, vision and values. 3. Positioning professional practice as a distinct service within the organization (e.g., separate from education, programs and human resources) in order to highlight the unique areas of focus for professional practice (e.g., scope of practice versus training). www.mtsinai.on.ca We would like to pay tribute to our remarkable staff who have worked tirelessly throughout the SARS emergency. Your heroic efforts are a testament to your dedication and caring for our patients. We thank you and salute you. Dedicated to discovering and delivering the best patient care We are a fully accredited hospital and equal opportunity employer. A WORLD CLASS FACILITY IN THE HEART OF TORONTO Flexible, Non-Silo Approach Challenges Identified Although program management was implemented to decrease the silos between traditional departmental structures, some would argue that it has created a new set of silos: between programs, between operational (program) and professional areas and between professions. The introduction of the Regulated Health Professions Act generated and continues to generate passionate dialogue regarding unique versus overlapping scopes of practice. This lack of consensus has resulted in what may be viewed as the creation of professional silos as professions attempt to carve out (some may say stake out) their unique areas within an interprofessional team environment. Collaborative practice depends on each unique profession and a collective understanding among professionals regarding scope of practice and overall contributions to client outcomes.
70 Nursing Leadership Volume 16 Number 2 Strategies Shared 1. Creation of an interprofessional forum to provide opportunities for knowledge sharing regarding issues that might affect a few or a large variety of professionals across the organization. This strategy provides an opportunity to enhance understanding of profession-specific issues as well as interprofessional issues. Membership includes representation from all professions (including medicine), with direct accountability to senior management. Examples include Professional Advisory Council, Interprofessional Affairs Committee, Clinical Practice Committee. 2. Creation of profession-specific forums to provide an opportunity for each distinct profession to focus on unique aspects of scope of practice, regulatory requirements and quality assurance requirements. It is vital for the individual professions to understand their own scope in order to enter into a larger dialogue regarding interprofessional and collaborative practice. 3. Direct connection or affiliation of professional practice leaders to distinct programs.this relationship helps to enhance communication and consultation and avoids duplication of efforts. Effective Physician Linkages Challenges Identified The most significant challenge identified was Ontario s Public Hospital Act. This piece of legislation speaks only to the medical profession and does not recognize other disciplines as independent professions with distinct scopes of practice. The legislated aspects of the Medical Advisory Committee (MAC) and the reporting subcommittees are viewed as no longer reflective of the broader practice environment in healthcare. In many organizations, MAC is often viewed as maintaining a very operational focus and functioning independently or parallel to existing professional practice structures. Although some groups have physician representation incorporated into their terms of reference, few have the benefit of consistent, active physician involvement in interprofessional forums. A significant challenge is to revise the existing mental model of MAC within the context of its role as the professional practice forum for physicians and establish active physician involvement in professional practice issues. Strategies Shared 1. Identification of physician champions willing to provide active and vocal support for professional practice models and roles for all professions. The Magnet Hospitals research identified the significance of the nurse-physician relationship at both the micro and macro levels in terms of respect and professional autonomy (Kramer and Schmalenberg 1988). 2. Positioning of a senior professional practice role as a voting member on MAC. In keeping with the culture of collaborative practice, this strategy allows for key stakeholders to be kept informed of key issues and to identify potential
Describing the Essential Elements of a Professional Practice Structure 71 areas of overlap or conflict. Organizations that have this feature in place find the variety of perspectives at the table to be invaluable. 3. Active physician representation on, and participation in, interdisciplinary professional practice council/committee. This strategy provides an avenue for knowledge sharing regarding scope of practice, impact of practice initiatives (e.g., best-practice guidelines) and research on the professions. Conclusion As a result of this facilitated exercise, it became clear that although most organizations espouse a professional practice culture, there is great variability in the degree of operational supports in place to achieve that culture. These operational supports go beyond the allocation of resources to include a vision for professional practice that is embraced by the organization as valued added, not only to professional satisfaction and competency but also to client outcomes. The Magnet Hospitals research clearly identified the existence of professional practice models as an attribute for successful hospitals (Kramer and Schmalenberg 1988). But the challenge for those in professional practice roles is the lack of research and empirical evidence to demonstrate the key elements that should be in place in order for professional practice structures to be successful. There is a need for research to identify structural elements of successful professional practice models in order to demonstrate the rationale for organizational investment. As for the members of the PPNO, this exercise provided a snapshot of a diverse, evolving professional practice structure that continues to grow along with the healthcare environment. We look forward to actively contributing to how the picture will look in the future. References Comack, M., J. Brady and T. Porter-O Grady. 1997. Professional Practice: A Framework for Transition to a New Culture. Journal of Nursing Administration 27(12): 32 41. Kramer, M. and C. Schmalenberg. 1988. Magnet Hospitals: Part I. Institutions of Excellence. Journal of Nursing Administration 18(1): 13 24. Kramer, M. and C. Schmalenberg. 1988. Magnet Hospitals: Part II. Institutions of Excellence. Journal of Nursing Administration 18(2): 11 19. Porter-O Grady, T. 1998. Implementing Shared Governance: Creating a Professional Organization. Mosby Year Book. Williams, B. 2001. Developing Critical Reflection for Professional Practice Through Problem-Based Learning. Journal of Advanced Nursing 34(1): 27 34. For information about the Professional Practice Network of Ontario, contact: Sara Lankshear at slankshear@aol.com. Make this journal available on line to all your colleagues Ask about low-cost or even no-cost e-subscriptions. Contact Susan Hale for details: shale@longwoods.com
72 Nursing Leadership Volume 16 Number 2 Commentary A Demonstration of Ingenuity Heather Mass, RN, BN, MSC Chief of Nursing Children s & Women s Health Centre of British Columbia, Vancouver The leadership challenges identified by Mathews and the members of the Professional Practice Network of Ontario (PPNO) will not come as a surprise to anyone in a leadership role in healthcare today. Much has been written about leadership gaps and the challenges for healthcare leaders in building quality practice environments. The sources of the current challenges have been attributed to the shattered covenant between leaders and workers arising from an era of downsizing and a resulting loss of trust in leaders (Noer 1993). Porter-O Grady (2003) states that the role of the leader in the new world is to create congruence by assuring a sustainable future for the organization while at the same time advancing the value and viability of those whose efforts lead to organizational success. He also notes that during periods of significant transition the complexity, time limits and intensity of the work of change are impossible for an individual leader to address alone. The first challenge identified by the PPNO is a good example of this complexity. The creation of formal communication channels and clear authority for professional practice leaders is complicated by reorganization and mergers of organizations and facilities, the creation of professional leadership positions and the evolution of practice based on research evidence. These changes create new organizations that in turn lead to the need to create new cultures. Similarly, the introduction of models such as program management were designed to break down department structure silos. Instead, they have led to the creation of new program silos that present problems for communication between and across programs related to specific clients and with professional leaders related to professional issues. They have also served to disenfranchise part-time and shift workers who are unavailable to be consistent members of the program team creating yet another silo. The concept of structures that incorporated physician co-leadership was intended to help build strong links between physicians, the organization and other disciplines. However, the perceived lack of discipline leadership for professional issues within programs reinforced the perception that the MAC must be the voice for both operational and professional
Commentary: A Demonstration of Ingenuity 73 issues. The creation of disciplinespecific leadership positions and the development of discipline-specific practice councils, such as nursing councils, also evolved from this gap. On the bright side, the professional autonomy over practice that withindiscipline leadership promotes, together with effective multiprofessional practice councils as recommended by the PPNO to enhance potential for effective communication, creates two of the essential preconditions for the development of a magnet organization (Havens and Aiken 1999). The creation of an interdisciplinary network (the PPNO) for the facilitation of interdisciplinary dialogue on professional practice leadership goes a long way toward addressing the very challenges identified in Mathews paper. As noted by Homer-Dixon (2000), when things happen faster, in greater numbers, and with greater interactive complexity, we need more ingenuity to make the right decisions at the right time. Clearly, the PPNO is demonstrating ingenuity in sharing ideas and practical solutions. Given this success, other provinces and health authorities might consider the benefits of creating such networks. References Havens, S.S. and L.H. Aiken. 1999. Shaping Systems to Promote Desired Outcomes The Magnet Hospital Model. Journal of Nursing Administration 29(2): 14 19. Homer-Dixon, T. 2000. A World That Turns Too Fast. Financial Times (London), January 2, 2001. Retrieved May 18, 2003. www.homerdixon.com/pop/fast_bottom.htm. Noer, D.M. 1993. Healing the Wounds.San Francisco: Josey-Bass. Porter-O Grady, T. 2003. A Different Age for Leadership Part 1 New Context, New Content. Journal of Nursing Administration 33(2): 105 10. The Ontario Hospital Association (OHA) is pleased to announce the first annual Award of Excellence in Nursing Leadership. This award will acknowledge outstanding leadership of an individual nurse in a senior leadership position who is employed in a member organization (Hospitals, Affiliates and Associates) of the OHA. The award will be presented at the annual OHA Convention & Exhibition each November. Nominations for the inaugural award will be accepted until August 15, 2003. For more information go to: www.nursingleadership.net or www.oha.com and follow the links.