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  • Professional Practice Model

  • The Miriam Hospital's philosophy and definition of professional nursing is consistent with the RI State Nurse Practice Act. The Act states that "the practice of professional nursing is a dynamic process of assessment of an individual's health status, identification of care needs, determination of health care goals with the individual and/or family participation, and the development of a plan of nursing to achieve these goals.

    Nursing actions, including teaching and counseling, are directed toward the promotion, maintenance and restoration of health and evaluation of the individual's response to nursing actions and the medical regimen of care.

    Our professional practice model is aligned with professional and accrediting agency standards and the hospital's strategic plan and initiatives. The ANA's Principles of Nurse Staffing are utilized in the allocation of nursing resources and in preparation of patient assignments. Considerations for continuity of care and nurse competencies are integrated into our Model of Care. Key tenets of this model include the following:

    • Accountability/Engagement
      Our nurses serve in the role of coordinator of care, which is delivered with compassion and competence. Engagement is incorporated to further define the advocacy, moral agency, and vigilant engagement required for holistic care of the patient.
    • Communication
      The RN is responsible to effectively communicate with the multidisciplinary team, in order to exchange information related to the patient's care. The multidisciplinary team includes the patient, family and health care providers. Healthcare disciplines are consulted for their expertise. The RN is responsible to communicate with the patient and family, incorporating patient education and information in all aspects of their practice. RN to MD communication focuses on facilitation toward desired patient outcomes. Collaboration will provide continuity of care to patient/family, development of goals and evaluation of care outcomes. The staff nurses expressed that much valuable information and collegial exchanges were lost when silent report was instituted. The following are components of this tenet:
    • Collaborative Practice
      The RN is responsible to ensure continuity of care involving coordination of all disciplines in arriving at an interdisciplinary plan of care for the patient. The RN facilitates the contributions of all disciplines toward optimal and realistic goals for the patient. Continuity of care will be maintained in assignment of patients. Processes and persons will be continuous and consistent in recognizing the holistic interrelationships that exist in the healthcare system.The RN will incorporate the multi-disciplines in addressing the diversity of each patient and recognize differences in the provision of each patient's care.
    • Control Over Professional Practice Environment.
      This tenet further defined and set guidelines for our unit council structure. From this group and the leadership group came the recommendation for a Unit Council Steering Committee. The RN will make judgments collectively to change policies, procedures, and clinical and administrative practice, with a focus on optimal patient outcomes. The vehicles through which staff institute change include unit councils, hospital wide committees with nurse representation, and collaboration with the Nurse Manager/CNO. Nurses have input and exert power and control in issues affecting nursing and patient care. Nurses are viewed as integral to the hospital's ability to provide patient care services.

      Nurses contribute to the hospital's positive presence through participation in collaborative partnerships with the community or personal involvement at the community, national or international level.
    • Autonomy (individual decision making for the patient). Nurses are empowered to make independent clinical decisions, beyond usual standard of practice, within the scope of the Nurse Practice Act. Leaders foster an environment that encourages and recognizes autonomy in a non-punitive environment. Feedback on unsuccessful actions is constructive and is discussed for educational purposes and the measurement of patient outcomes.

    Nursing Care Delivery System/Modified Primary Nursing

    Principles of Primary Nursing

    1. The responsibility for the care of patient, or groups of patients, rests exclusively with the Registered Nurse. The primary nurse role incorporates both direct care provider and patient care management components.
    2. The nurse is the primary caregiver and cannot delegate authority. Others may assist the nurse in the provision of direct care, while the nurse maintains overall responsibility for the patient. Support staff assisting with direct care will be prepared at a competency level appropriate for the care requirements of the specific population of patients within the context of regulatory requirements.
    3. The core elements of primary nursing include: Continuity of care for the patient, the accountability of the nurse for the patient's care, and care that is comprehensive, individualized and coordinated.

    The Miriam Hospital implements a modified primary nursing care delivery system, based on the three principles of primary nursing. The modified primary nursing care delivery system recognizes that no one individual is accountable for patient outcomes, but rather, the care team and each individual are accountable for patient outcomes. The nursing team includes nurse manager, clinical nurse leader (CNL), clinical coordinator, registered nurse (RN), collegiate nurse intern (CNI), and certified nursing assistant (CNA). Advanced practice registered nurses (APRNs) and the case management team are also accountable for patient care.

    The modified primary care nursing care delivery systemincorporates:

    • Geriatric Friendly Nursing Care.
      Geriatric friendly nursing care is provided via the GENESIS program, a nursing implemented program with a three pronged approach, involving education related to essential aspects of geriatric nursing care, environmental considerations for care, and the use of protocols. Ancillary personnel work under the direction of the RN.
    • Advanced Practice Registered Nurses.
      Advanced practice nurses are used throughout the organization. Clinical nurse specialists, nurse practitioners and nursing managers are available for consultation.
    • Case Management.
      Case managers are RNs, and as members of a multidisciplinary team, collaborate with physicians, nurses, and medical directors. Case managers coordinate, facilitate, and expedite patient care services across the continuum by:
      • Identifying patients and/or families with complex psychosocial, non-medical discharge-planning issues, including continuing care needs such as provided by home health services, hospice or nursing home placement
      • Determining appropriate referrals, facilitating placement in alternative care settings, and negotiating on behalf of the patient and the hospital with external third parties for cost-effective, high quality alternatives to hospital level of care.
      • Conducting concurrent reviews of medical record documentation to ensure adequacy and completeness and that documentation supports the clinical status of the patient to ensure proper reimbursement of third-party payers
    • Shared Governance.
      Unit councils, committee representation and advancement programs are vehicles through which staff are empowered to make collective decisions.
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