Chapter 18: The Division of Nursing: An Overview, the Professional Practice Model, and the Development of Nursing as an Autonomous Field
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Description
Dr. Summers describes the organization of the Division of Nursing and major projects undertaken since she assumed leadership in 2003 to ensure that all membered are appropriately licensed and credentialed and that they are always developing nursing practice.
Next she speaks in detail about the Professional Practice Model refering to the “quality care model” depicted in an image produced for the Division. (See transcript for image used during this discussion.) She talks about elements of primary team nursing; self-awareness; professional partnerships; and professional recognition.
Dr. Summers also explains what “achieving autonomy” means for professional nursing and why it is so important to the development of the field. She sketches some of the history of nursing.
Dr. Summers goes on to explain how a team at MD Anderson created the model, revising a practice model in place when she took over the Division. She unique working environment for nurses at MD Anderson and sketches the varied areas in which they function.
Identifier
SummersB_03_20140429_C18
Publication Date
4-29-2014
Publisher
The Making Cancer History® Voices Oral History Collection, The University of Texas MD Anderson Cancer Center
City
Houston, Texas
Interview Session
Barbara Summers, PhD, Oral History Interview, April 29, 2014
Topics Covered
The University of Texas MD Anderson Cancer Center - An Institutional UnitThe Administrator The Leader Contributions to MD Anderson Professional Practice Understanding the Institution On Leadership The History of Health Care, Patient Care Institutional Mission and Values The MD Anderson Brand, Reputation
Creative Commons License
This work is licensed under a Creative Commons Attribution-Noncommercial-No Derivative Works 3.0 License.
Disciplines
History of Science, Technology, and Medicine | Oncology | Oral History
Transcript
Tacey Ann Rosolowski, PhD:
And where would you like to start? You had wanted to address the Nursing Practice Model and then wanted to talk about the Division of Nursing, and, I don’t know how do those things come together. Where is a good place to start to tell that story and the relationship between those things?
Barbara Summers, PhD:
Well, I think one place to start is to expand upon the definition, if you will, of Division of Nursing, because the Division of Nursing is not confined to the inpatient hospital administration. Actually, the Division of Nursing is not at all synonymous with inpatient operations. The Division of Nursing is the entire community of professional nurses at MD Anderson Cancer Center, so that includes all nurses practicing in clinical positions, in advanced practice nursing positions, in positions where they’re supporting clinical research, so it really is the organizing structure for professional nursing practice. One of the key responsibilities of the Chief Nursing Officer is to ensure that the members of the Division of Nursing are appropriately licensed and credentialed, that we are continually developing the knowledge, skills, and abilities of our professional nursing members, and that we are advancing the capacity of the professional nurses to govern their own professional practice. So that is very different from my role running the inpatient side of the organization and the hospital. And as we think about the Division of Nursing and the practitioners of nursing in the organization, an element that is critically important for nurses practicing in any setting is that we are able to reference a foundation that is our Professional Practice Model that describes the ways in which nurses think about their practice and engage in their practice. So we have probably in the last eight years really focused on our Professional Practice Model, and in the last three years we have completed an intensive review and revision of our Professional Practice Model, and that was accomplished through our nursing governance structure that included a team that was a cross-sectional representation of nurses practicing in every role at MD Anderson. So the Professional Practice Model incorporates our core values of the institution of caring, integrity, and discovery, but it starts at the center with relationship-based caring. And the focus of relationship-based caring is that one feels cared for and feels cared about, and that is our Quality Caring Model. And interestingly, the relationship-based caring occurs with the nurse and the patient and family, the relationship with the nurse and the interprofessional teams members, the nurse and the community, but equally important, the nurse in relationship with self, having self-awareness and engaging in self-care. And this is a fundamental tenet from the Quality Caring Model from Dr. Joanne Duffy, who developed the Midrange Theory on Quality Caring, and her proposition is that unless one cares for oneself, we are hampered in our ability to engage in caring relationships with other individuals or teams. Then the structures or components that support our Quality Caring Model include our patient care delivery system which we call primary team nursing, the notion of professional partnerships, which are the collaborations that we have internally as well as externally, internally with our interprofessional colleagues, externally with professional nursing colleagues, professional organizations, etc. Professional recognition is a key component of our Professional Practice Model where nursing expertise is visible, highly visible, and we make sure it’s visible, that it’s valued, and that nursing expertise is understood. Professional recognition also includes maintaining professional autonomy, where nurses continue to own the independent portion of their nursing practice.
Tacey Ann Rosolowski, PhD:
Now, you’ve mentioned the issue of autonomy several times. Why is that such a key element?
Barbara Summers, PhD:
Autonomy is a key element in professional nursing practice because when nurses receive their license to practice, they are, in fact, licensed to deliver nursing care to patients independent of any other interprofessional provider, so they do not have to rely upon physicians to write medical orders for nurses to engage in nursing practice to care for patients. There is an independent portion of practice in nursing. There is an interdependent portion of practice in nursing. It’s in the interdependent component of our practice where we collaborate with physicians and other team members in the interdependent realm when a physician will generate medical orders and nurses will partner with the physician in carrying out those orders if it is, for example, performing a treatment with the patient or delivery a medication to the patient. But nursing practice is not defined by those things that physicians order for patients to be done. So it’s very important that nurses continue to remind themselves and focus on the independent autonomous portion of their practice, which is what differentiates and defines the role of the professional nurse.
Tacey Ann Rosolowski, PhD:
I picked that up and was thinking about kind of the traditional view of nurses that I remember from when I was a child, as doctor’s helper.
Barbara Summers, PhD:
Doctors’ helpers. Exactly.
Tacey Ann Rosolowski, PhD:
So it’s interesting that this is now being theoretically built into the way that nursing is conceptualized and kind of addressing that old assumption. To what degree do people still hold that assumption about nursing?
Barbara Summers, PhD:
I think that there is still a significant number of people who believe that nursing practice is, in sum, the carrying out of the physician’s orders and being a doctor’s helper. Nursing as an autonomous professional practice, though, has roots back into the 1960s. I remember as I was getting my baccalaureate degree in the seventies and we were studying nurse theoreticians and identifying the professional practice role of nurses at that time focusing on a theory of nursing called the Theory of Self-Care developed by Dorothy Orem, where the primary function of nurses was to serve as substitute self-care agents on behalf of the patient, performing for the agent those things that they would do for themselves if they could, if they were able. So that’s why we emphasize in this Professional Practice Model our professional nursing values of autonomy, accountability, and excellence in practice. That’s why we emphasize our nursing shared governance, which is a multidisciplinary shared decision-making body, but always keeping at the top of mind that our duty is to the patient as a nurse. That is our solemn duty to the patient and family, not to MD Anderson, not to the chief nursing officer, not to the president of MD Anderson, but my license says that my duty is to my patient. And then—go ahead.
Tacey Ann Rosolowski, PhD:
Well, I just wanted to ask you where this practice model came from. Is that something that you developed? Where did it evolve?
Barbara Summers, PhD:
The practice model was developed by this team of nurses that I referenced earlier, who were formed out of our nursing governance structure called Nursing Practice Congress, which included a cross-section of nurses in all roles in the organization and involved an extensive review of the literature, going through a values-clarification exercise so that we would understand our professional values, selecting a theoretical framework for nursing practice. And the Duffy Quality Caring Model was selected as the theoretical framework, identifying the structural components of our Professional Practice Model that include the professional recognition, the patient care delivery system, our shared governance structure, our professional partnerships and then taking Duffy’s Quality Caring Model and focusing on what are called caring factors, eight caring factors in Duffy’s model, which are the unique contribution of nurses to the caring relationship that occurs with patients. You know, we don’t believe, and Dr. Duffy doesn’t state, that nurses are the only professionals who care for patients. All professionals who are healthcare providers go into the profession because they want to engage in compassionate, caring relationships with others, but nurses are the profession that uniquely use caring interventions to promote health and healing. So nurses use caring as a method of promoting health and healing in patients, so that includes such activities or factors as what we call mutual problem-solving, where nurses help patients and their family members to address, confront, and learn about their illness and their current health state and then enhance the ability of the patient and family to participate in decisions about their care. So that’s mutual problem-solving. That’s an intentional intervention on the part of nurses. Another intentional intervention that nurses use is something called attentive reassurance, where nurses make a conscious effort to be fully and authentically available to the patient and fully attentive to the patient, where we can reflect back to the patient what we are seeing them express to us, so that the patient can then have that clarity to begin the process of healing. Nurses also, of course, provide care to meet the basic human needs of our patients, that we understand every human being has basic physiological needs, basic needs for love and belonging, basic needs for self-actualization, and we support patients in meeting those needs when they often can’t do that for themselves. So there are eight caring factors in our model that describe the ways that nurses practice which uniquely provide healing for the patient, in addition to the nurse’s clinical skill set of being able to perform a physical assessment and identify abnormalities, and in addition to the nurse’s ability to sit and teach a patient about a new medication, in addition to the nurse’s ability to deliver medication that has been ordered by a physician, in addition to the connecting work that nurses do where they are communicating key points of information from the patient to other care team members or among the care team members. So we’ve really intentionally focused a great deal of time, effort, and energy on our Professional Practice Model because we want nurses to continually be reminded of the unique professional contribution that they bring to the healthcare delivery setting so that they don’t fall into the trap of valuing their worth in terms of how well they are helping physicians.
Tacey Ann Rosolowski, PhD:
What is the impact—well, first let me ask when did you launch the Professional Practice Model and how have you seen its impact evolve?
Barbara Summers, PhD:
Well, we had one when I became Chief Nursing Officer, although it was not well developed and well articulated, nor was it well understood by most of our nurses.
Tacey Ann Rosolowski, PhD:
And you became—2003 is when you [unclear].
Barbara Summers, PhD:
2003. And probably in maybe 2006 we began a process of refining that Professional Practice Model, and we used the same approach of bringing together cross-section of nurses. We developed a Professional Practice Model that it was overly complicated to the point that it was even difficult for me to explain it, and it had no resonance with the clinical nurses because they couldn’t understand it either, even though a group that included clinical nurses had developed it. It was just far too complicated and not practical. So, consequently, we, in 2011, I think, began the process of again going back to basics and saying, “Let’s start over again and develop a Professional Practice Model that includes our values, that speaks to the innate contributions of nurses, but let’s create a model that has resonance with nurses at every level and that is something that has enough resonance that anyone can explain it.” So that’s kind of been the evolution over time.
Tacey Ann Rosolowski, PhD:
And what’s the impact now, now that nurses at MD Anderson are actively working with or kind of absorbing and working with this model?
Barbara Summers, PhD:
You know, I think the impact is probably one of those intangibles, although in speaking with nurses—and actually I write monthly about the caring factors and the way I use these caring factors in my leadership practice, and I invite nurses to submit stories to me about the ways they apply their caring factors.
Tacey Ann Rosolowski, PhD:
And you write about this in what venue?
Barbara Summers, PhD:
In an email that’s distributed to all nurses. So I think it just starts to get them to think about, “Okay, how do I use mutual problem solving with my patients?” and heightens their awareness. And then when I have the opportunity to speak with nurses and ask them about offering an encouraging manner with patients, like, “How are you conveying messages of support to your patients and their families? And how are you demonstrating your openness to individuals expressing their feelings? If they’re particularly angry, how are you demonstrating your openness to hearing them talk about them?” It just allows them verbally to reflect on the ways that they are practicing nursing, which then just strengthens their identity as a professional nurse with an independent duty to their patient. So there’s not like a meter that we use to measure nursing adoption or internalization of Professional Practice Model. It’s really a culture—I don’t want to say a change, but a culture enhancement.
Tacey Ann Rosolowski, PhD:
And are other cancer institutions creating practice models of this kind? I mean, because one of the questions I wanted to ask you is, you know, what about oncology nursing here at MD Anderson vis-à-vis other cancer centers? How does this practice model enhance the strength of oncology nursing here?
Barbara Summers, PhD:
Well, you know, I would say any top organization, top-performing organization, is going to have their own nursing Professional Practice Model, and the neat thing about it is that it has to be a model that is resonant with the nurses who practice in the organization and is reflective of the ethos of the nursing practice in the organization. So there can’t be just a standard model that you plug and play in any organization. It really has to be an effort that is organic and grows out of the practice of the nurse. So there indeed other comprehensive cancer centers that have nursing Professional Practice Models that are different than our Professional Practice Model but that, nonetheless, have the same goal of providing the framework and structure for nurses to ground their professional practice.
Tacey Ann Rosolowski, PhD:
Very interesting. Now, do you travel to talk about this practice model? Have you given papers on this practice model, I mean, sort of what the MD Anderson take is on Professional Practice—I mean, it’s very interesting. Essentially it’s a reflection of the culture and strengthening the culture.
Barbara Summers, PhD:
It is. And the short answer to that is no, not yet. We’ve done quite a bit in terms of presenting and writing about our patient care delivery system primary team nursing, which is one component of the Professional Practice Model. I want to see papers written and presentations given about our Professional Practice Model and how it lives and breathes in our organization. But we’ve been, I think, more focused on deploying the model and having conversations with nurses regarding the model so that we really feel that it is deeply internalized and hardwired into their practice.
Tacey Ann Rosolowski, PhD:
And how have you deployed the model?
Barbara Summers, PhD:
Oh, there’s an entire plan for the implementation, dissemination and implementation of the Professional Practice Model that involves the communication from the nursing leaders at every level as well as champions of the Professional Practice Model at every level and multiple types of communication that go out for the staff to consume on the PPM, and we have a brochure on it. We have areas of focus for what we call team huddles, which are very short staff meetings, where we focus on a component of the model, one of the structural components or one of the caring factors. We highlight the use of the Professional Practice Model in our town hall meetings. We at Nurses Week this year are going to be focusing on the human caring factors as we celebrate Nurses Week during our big town hall—what we call the Dr. Summers Show. It’s like a talk show. But I’m going to be giving away Nurses Week gifts that focus on, for example, basic human needs. So I’m giving away gift cards to local restaurants in recognition of basic human needs. So anyway, we just use lots of different strategies to get that out there.
Tacey Ann Rosolowski, PhD:
And what’s been the response?
Barbara Summers, PhD:
Oh, I think nurses like it. I mean, it’s great because it reminds us of what we do and what’s unique about nursing and why we went into nursing to begin with.
Recommended Citation
Summers, Barbara PhD and Rosolowski, Tacey A. PhD, "Chapter 18: The Division of Nursing: An Overview, the Professional Practice Model, and the Development of Nursing as an Autonomous Field" (2014). Interview Chapters. 1255.
https://openworks.mdanderson.org/mchv_interviewchapters/1255
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Open
