ONLINE EXCLUSIVE 1

Professional Practice in Nursing:

A Framework

Francine Girard, RN, BN, MN, PhD

Senior Vice President, Professional Practice and Research
Chief Nursing Officer
Calgary Health Region
Calgary, AB

Noreen Linton, RN, BN, MN

Director, Chief Nursing Portfolio
Calgary Health Region
Calgary, AB

Jeanne Besner, RN, PhD

Director, Research Initiatives in Nursing and Health
Calgary Health Region
Calgary, AB

Abstract
Ensuring that nurses can practise according to the philosophical underpinnings of their
profession is recognized as an important factor in job satisfaction and is therefore a
key element of retention and recruitment of the nursing workforce. Creating a culture
of excellence requires making explicit a set of values and performance expectations
to which all nurses can subscribe and that influences practice behaviours. The vice
president and chief nursing officer of a large health region in Western Canada there-
fore sought to establish a foundation for building such a culture of excellence, through
the creation of a mission, vision and Professional Practice Framework for the region’s
nurses. The author describes the development of the nursing Professional Practice
Framework for this health region, presents the results of a participatory approach to
promoting nurses’ ownership of the model and discusses plans for assessing the impact
of the framework on nurses’ practice and patient care.
2 Nursing Leadership On-line Exclusive • June 2005

The past decade in healthcare has been characterized by hospital restructuring, with
mergers of previously independent organizations and their associated cultures into
larger, regionalized entities. Concurrently, cutbacks due to fiscal constraints during
the 1990s contributed to heavy workloads, long hours and reported difficulty by
nurses in carrying out their professional roles (Baumann et al. 2001). Recognizing
the importance of practice environments that conform to the philosophy of care
held by the nursing profession (Baumann et al. 2001), many organizations have
developed professional practice models to guide nursing care delivery, with the goal
of empowering the nursing workforce and improving the quality of patient care
(London Health Sciences Centre 2004; Ottawa Hospital 2004; University Health
Network 2004).

The newly appointed vice president and chief nursing officer (CNO) of the Calgary
Health Region (“the Region”) requested that the Regional Nursing Council begin
work on developing a Professional Practice Framework for nursing. A task force was
struck, with a mandate to complete a first draft of the framework by Nursing Week
(May 2003).

This paper describes the process used to solicit input into the development of the
framework and presents results of the participatory approach to obtaining owner-
ship of the model by nurses. It concludes with a brief commentary on plans for
assessing the impact of the framework on nurses’ practice and on patient care.

Literature Support
Ensuring that nurses can practise according to the philosophical underpinnings
of their profession is recognized as an important factor in job satisfaction and
hence is critical to retention and recruitment of the nursing workforce (Baumann
et al. 2001). Employers share responsibility with nurses, professional associations
and others for promoting environments that support quality professional practice
(Canadian Nurses Association 2001). Achieving high-quality healthcare requires
that we make explicit the expectations related to professional nursing practice
(Ferguson-Pare et al. 2002). Nurses’ effectiveness in achieving the outcomes for
which they are accountable is inextricably tied to the extent to which they can
exercise control over the delivery of care for which they are responsible (Hoffart
and Woods 1996). Professional practice models generally address nurses’ need
for autonomy and accountability and are considered important to organizational
empowerment of nurses and to the creation of effective work teams (Spence
Laschinger and Havens 1996). A set of values and performance expectations to
which all nurses can subscribe and that influences practice behaviours is essential
to creating a culture of excellence (Kramer 1990). Achieving excellence in nursing
practice was the aim in development of the Calgary Health Region Professional
Practice Framework.
 Professional Practice in Nursing: A Framework 3

Development of the Framework

One of the first priorities of the vice president and CNO of the Calgary Health
Region was to develop a vision for nursing in the Region. Through the development
of this vision, it became apparent that a mission for nursing was also essential. As
this work progressed, an evident need emerged to establish a definition of profes-
sional practice and a guideline or framework that nurses could utilize on a daily
basis to achieve the vision and mission of nursing in the Region. This foundational
work is described in Figure 1.

The mission and vision formed the foun-

dation on which development of the
Figure 1. Vision and mission for
Professional Practice Framework was based. nursing, Calgary Health Region
An important first step was to articulate
clearly, in concise terms, the meaning of Our vision for nursing:
“professional nursing practice.” Consultation Excellent healthcare through
with nurses in the Region provided the professional nursing practice.
substance from which the following defini- Nursing mission:
tion was crafted: We are committed to professional
nursing practice that promotes
Professional nursing practice is a quality, family-centred care and
commitment to compassion, caring efficient and effective delivery
and strong ethical values; continuous of integrated services provided
in collaboration with community
development of self and others; account- partners and members of the
ability and responsibility for insight- multidisciplinary healthcare team.
ful practice; demonstrating a spirit of
collaboration and flexibility.

One of the main concerns of the task force mandated with the development of the
Professional Practice Framework was that all nurses be given the opportunity for
involvement in its development. Hence, a participatory approach was used to solicit
nurses’ input. A number of focus groups were held, which were offered at different
times of the day on various days of the week and at various sites across the Region.
Subsequent to analysis of the focus group data, questionnaires to validate the focus
group findings were distributed in hard copy at all regional sites and simultaneously
placed on the internal website to increase access for nurses in the Region and to
invite them to complete the survey.

Purpose and Objectives

The purpose of the focus groups was to obtain nurses’ views about the defining
elements of professional nursing practice within the Region. Three questions were
asked of participants in the focus groups, only the first of which is addressed in this
paper:
4 Nursing Leadership On-line Exclusive • June 2005

1. How would you describe an exemplary “professional” nurse?

2. In light of those attributes, what do you think is the current status of professional
nursing practice in the Calgary Health Region?
3. What can the Region do to support and promote professional nursing practice?

Methodology and Limitations

Eighteen focus groups were held from early January to late February 2002, with a
total of 156 participants in attendance. Three of these focus groups were considered
“expert” groups, two with the Regional Nursing Council and one with representa-
tives of the clinical nurse educators. The remaining 15 groups were composed of
nurses (primarily registered nurses, with a few licensed practical nurses) working
in a variety of practice settings (e.g., home care, public health, acute care) and sites
(hospitals and community-based offices or clinics).

All focus groups were moderated by one of two facilitators who were employees
of the Region. Group discussions were either audiotaped and later transcribed,
or summarized directly onto a laptop computer by one of the group moderators.
Subsequent to the focus groups, a questionnaire was constructed and a Region-
wide survey conducted with nurses to validate the components of the Professional
Practice Framework. Statements on the questionnaire were derived from the
themes that had emerged during focus group consultations. These included eight
statements focusing on the art of nursing, eight related to competence, eight deal-
ing with attributes of practice and 10 with personal commitment. A total of 482
respondents returned a completed questionnaire. Consistently, respondents indi-
cated high agreement with the statements on the questionnaire, confirming that the
elements of the framework that had emerged from the focus groups resonated with
the larger sample of nurses in the Region.

Respondent Profile
Almost all respondents to the survey were registered nurses (RNs). A majority
(44%) held a baccalaureate degree in nursing, closely followed by diploma-prepared
nurses (40%). A small number of respondents (9%) were prepared at the graduate
level. Only 2% of respondents were licensed practical nurses (LPNs) and 3% were
registered psychiatric nurses (RPNs). The proportion of LPN and RPN respondents
was only slightly less than their proportional numbers in the total nursing staff mix
of the Region at the time the survey was conducted. More than half the respondents
(51%) worked in acute care settings. Public health (11%), ambulatory care (10%)
and home care settings (10%) were equally represented, followed closely by mental
health (8%). Only 3% of respondents held administrative positions. Three-quarters
(74%) of respondents had 10 or more years’ experience in nursing, compared to
only 3% with less than one year in nursing practice. Respondents with one to four
(11%) or five to nine (11%) years’ experience were equally represented.
 Professional Practice in Nursing: A Framework 5

Discussion of Results
From focus group comments and their subsequent validation through the quantita-
tive survey, a draft Professional Practice Framework was presented for consideration
and further development by the Regional Nursing Council. The components that
follow were derived from nurses’ input.

1. The art of nursing

Professional nursing practice is grounded in the art of nursing, described as taking a
holistic, client-centred focus; being caring and ethical in interactions with patients,
families and colleagues; having above-average interpersonal skills; and making sound
judgments based on experience and knowledge, thus averting potential problems.

2. Competence
Professional practice demands competence in relation to knowledge and technical
skills. This requires not only a broad base of knowledge, but also depth of knowl-
edge in a chosen area of practice, a desire and ability to continue developing that
knowledge base and to share it with others and critical thinking in decision-making.

3. Attributes of Practice
Professional practice reflects a particular approach to one’s work, with collaboration
by far the most salient characteristic. Professional nursing practice means work-
ing in partnership with other nurses and health professionals in providing client
care, being highly organized in managing activities and time, having the ability to
manage many complex tasks simultaneously, working autonomously as appropriate
and having an open mind and nonjudgmental manner.

4. Personal commitment
In describing this element of professional practice, respondents referred to the
importance of having confidence in one’s abilities and taking responsibility for
one’s actions, including having a sound understanding of the boundaries and limi-
tations of nursing practice. Having a balanced lifestyle and supporting the advance-
ment of the profession were also considered important characteristics of a profes-
sional nurse.

Approval of the Framework

After several months of consultations with nurses across the Region, discus-
sion at Regional Nursing Council and numerous revisions, the final draft of the
Professional Practice Framework was approved by Nursing Council and distributed
during Nurses Week 2003. The Professional Nursing Practice Framework for the
Calgary Health Region is depicted in Figure 2.
6 Nursing Leadership On-line Exclusive • June 2005

Figure 2. Professional Nursing Practice Framework, Calgary Health Region

A
S ION L NU
S

R
FE
THE ART OF NURSING

SI
PRO

NG
VI
SI

S
COMMITMENT

UE
ON

COMPETENCE
PERSONAL

L
VA
PATIENTS

PR RAC
OF TIC
P
ON

ES E
SI

SI
IS

ON
M

AL
ATTRIBUTES OF PRATICE

PR
ACTICE
The Art of Nursing Attributes of Practice
Nurses demonstrate ethical, insightful, caring Autonomous professional practice in nursing
practice by focusing on the health and well- requires taking personal responsibility for
being of individuals, families and communi- excellence in practice and effective collabora-
ties in health and during episodes of illness tion with multidisciplinary team members in
and transition. meeting the health needs of the population.

Competence Personal Commitment

Nurses’ competence is grounded upon nurs- Nurses demonstrate commitment to the
ing theory, scientific knowledge and experi- profession by valuing nurses and nursing,
ence, and is reflected in everyday practice. contributing to the advancement of the
It is enhanced through continuous learning, profession and continually striving for excel-
shared through mentorship and supported lence in patient care.
through intra- and interprofessional dialogue.

The framework is congruent with the values of the Calgary Health Region (Honesty,
Integrity, Dignity, Trust, Respect, Responsiveness, Creativity and Learning). It
reflects elements that are common to other professional practice frameworks
described in the literature (Behrend et al. 1986; Hannah and Shamian 1992 ; Hoffart
and Woods 1996; Joy and Malay 1992; University Health Network 2003). The
framework reinforces the prerequisites for the promotion of safe, competent and
ethical nursing practice that are inherent in the standards of practice and code of
conduct of the Alberta Association of Registered Nurses (AARN), the professional
body that regulates the practice of registered nurses in the province.

The framework was illustrated in a pamphlet distributed to all nurses in the Region
during Nurses Week. Incorporated in the pamphlet was a pocket card summariz-
ing the elements of the framework, providing a quick reference and enhancing the
 Professional Practice in Nursing: A Framework 7

likelihood that the framework would be utilized on a day-to-day basis as a guide to

practice.

The framework logo depicted in Figure 2 was designed by one of the members of
Regional Nursing Council (Sharon Witt) and is an expression of her belief that the
nurse’s cap has traditionally been an important symbol of professionalism in nursing.

Implementation of the Framework

Once the Professional Practice Framework was developed, it was important that it
“come alive” for all nurses practising in the Region. Numerous sessions were held
(some using telehealth technology) to familiarize nursing staff with the framework
when it was first launched, and introduction to the framework is now routinely
incorporated into the orientation of all new nurses who join the Region. The frame-
work also guides the development of preceptors and charge nurses.

The major elements of the framework have been linked to the expected RN, LPN
and RPN competencies articulated in job descriptions, and application of the
framework in practice is now incorporated into nurses’ ongoing professional devel-
opment and continuing education plans. A clinical mentorship program based on
the competencies associated with professional practice in the Region is under devel-
opment, as is a position paper on patient safety and professional nursing practice.

Further elaboration of the framework will be ongoing. For example, use of the
framework has exposed the need to clarify some of its terms, such as “insight-
ful practice.” Using a process not unlike that which guided development of the
Professional Practice Framework, input will again be sought to ensure that a defini-
tion of insightful practice is elaborated that will resonate with nurses in the Region.

Evaluation and Research

Now that the Professional Practice Framework has been articulated, it will be
important to determine the effectiveness with which it is being implemented across
the many sites and settings in this large regional health authority and measure its
impact on practice and patient outcomes. Over the course of the next several years,
specific implementation initiatives will be targeted for evaluation and research. An
overarching framework will be developed to guide the evaluation of specific initia-
tives. Answers will be sought to such questions as: What facilitated “internalization”
of the Professional Practice Framework? Did its implementation change nursing
practice on select units? Did changes in nursing practice affect the roles of other
members of the healthcare team? What difference, if any, did implementation of a
Professional Practice Framework make in job satisfaction and patient outcomes?
What went well in implementing the framework? What could have been done
differently?
8 Nursing Leadership On-line Exclusive • June 2005

Conclusion
The process of developing a Professional Practice Framework for the Calgary Health
Region demanded considerable time and effort on the part of a multitude of nurses.
The resolve to reflect accurately the language of nurses in developing the framework
was vital to defining professional practice in a manner that promoted ownership
of the final product by nurses in the Region. It will now be important to examine
the extent to which elaboration of this framework helps nurses achieve increased
meaning and continually strive to attain higher levels of excellence in their work. It
is hoped that the development of an explicit model to guide practice will ultimately
help nurses feel pride in their profession and value the tremendous contribution
that they and nursing make to the healthcare system.

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