The Department of Nursing Practice
Theoretical Framework for the Strong Nursing Practice Model
The SMH nursing practice model is based on systems theory, with specific
components derived from Sociotechnical Systems Theory (SST) (Pasmore, 1988),
Senge’s Fifth Discipline Model (Senge, 1990), and the Magnet Hospital Framework
(McClure, Poulin, & Sovie, 1983). Benner’s professional advancement framework (1982,
1984) was incorporated during a review and update of the model in 2007.
Strong’s Nursing Model focuses on patient and family-focused collaboration and
informed decision-making that is facilitated by an organizational structure and support
services that promote the generation of new knowledge, the development of highly
competent care providers, and the incorporation of evidence into practice. It is designed
to allow for maximum flexibility in accordance with unit or department demands, while
assuring hospital-wide consistency for expectations of quality patient care, effective and
efficient work environment, and maximum care provider and patient/family involvement
in care delivery processes and outcomes. The Strong Nursing Model is founded on the
assumption that structural, technological, and social components of the care delivery
environment contribute to effective care delivery practices and favorable outcomes for
employees and patients/families alike (Ingersoll et al., 2002).
Components of each of the three systems frameworks incorporated in Strong
Nursing’s Model reinforce and support the Department of Nursing’s overall mission to
improve health care through caring, discovery, teaching, and learning. In particular,
components of SST focus on the interplay between the work environment, technology,
and the social components of the organization’s culture (Happ, 1993; Pasmore, 1988).
SST stresses the organization’s need for flexibility and attention to the processes used to
create and deliver care. As such, it is applicable to clinical practice and to the
administrative oversight of nursing programs and services.
In the Fifth Discipline Model, systems thinking is defined as an essential
precursor to the production of extraordinary results (Senge, 1990). According to Senge,
work groups develop systems thinking through favorable interactions with others and an
ongoing process of continuous learning. As a result, organizations interested in
facilitating systems thinking must eliminate any factors that limit creativity, innovation,
and positive change.
The Magnet Hospital Framework stresses many of the work environment
elements evident in Senge’s Model. In the case of the Magnet Hospital Framework,
however, the focus is directed more broadly on the organizational and management
characteristics that promote autonomous decision-making and control over practice
(AACN, 2000; Kramer & Schmalenberg, 2003; Laschinger, Shamian, & Thomson,
© Strong Memorial Hospital, Department of Nursing Practice
2001). Less attention is paid to the learning component in Senge’s model, although
systems thinking and a systems approach to organizational change are clearly evident.
In keeping with SST’s flexibility-focused framework, nursing units and services
at SMH identify the best possible approaches for achieving unit goals and organizational
mission. Department of Nursing goals provide the overarching structure for the delivery
of nursing care, with specialty services, departments and individual unit nursing staff and
leadership creating the mechanisms for achieving these goals. Within the Strong Nursing
Model is a focus on collaboration, diversity, cultural inclusivity, engagement,
patient/family empowerment, and expert practice.
Consensus reached by the 2007 Practice Model Task Force convened to review
and update Strong’s Professional Practice Model resulted in the incorporation of
Benner’s professional advancement framework into the Nursing component of the
revised model. Benner (1982) patterned her work on the Dreyfus Model of Skill
Acquisition (1980) and found that the model can be generalized to nursing. In the
acquisition and development of a skill, a professional passes through 5 levels of
proficiency: novice, advanced beginner, competent, proficient, and expert. Increments in
skilled performance based on experience and education are taken into account.
Progression through these levels of proficiency mirrors the development of knowledge
and supports career development in clinical nursing (Mick & Ackerman, 2000). Benner
observed that professional advancement along a hierarchy of thinking, judgment,
behavior, and experience differentiates one level of practice from another. Nurses who
are at different levels of skills acquisition literally live in different clinical worlds
(Benner, 1992). While a beginner is mastering the organization, skills, and dexterity to
carry out tasks, the competent nurse accomplishes a plan of care and is able to predict and
control multiple activities and events related to the plan. At the expert level, the nurse no
longer relies on rules and guidelines to connect understanding of a situation to an
appropriate response. The expert nurse, with an extensive experiential background,
intuitively grasps the predominant issues of a clinical situation and is able to act without
experimenting along a continuum of possible solutions (Benner, Tanner, & Chesla,
1992). In the SMH model, expert practice is achieved through the combined influence of
nursing practice, organizational supports, and patient/family interactions. Dimensions
within these components support the learning, discovery, creativity, and recognition and
rewards aspects of magnetized settings that promote individual and group expertise.
References:
American Association of Colleges of Nursing. (2002). Hallmarks of the professional
nursing practice environment. Journal of Professional Nursing, 18, 295-304.
Benner, P. (1982). From novice to expert. American Journal of Nursing, 82, 402-407.
Benner, P. (1984). From novice to expert: Excellence and power in clinical nursing
practice. Menlo Park: Addison-Wesley.
© Strong Memorial Hospital, Department of Nursing Practice
Benner, P. (1992). Uncovering the wonders of skilled practice by listening to nurses’
stories. Critical Care Nurse, 12, 82-89.
Benner, P., Tanner, C., & Chesla, C. (1992). From beginner to expert: gaining a
differentiated clinical world in critical care nursing. Advances in Nursing Science,
14, 13-28.
Chisholm, R. F., & Ziegenfuss, J. T. (1986). A review of applications of the
sociotechnical systems approach to health care organizations. Journal of Applied
Behavioral Science, 22, 315-327.
Dreyfus, S., & Dreyfus, H. (1980). A 5-stage model of the mental activities involved in
directed skill acquisition. University of California: Berkeley. Unpublished
manuscript.
Happ, M. B. (1993). Sociotechnical systems theory. Analysis and application for nursing
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Ingersoll, G. L., Schultz, A. W., Hoffart, N., & Ryan, S. A. (1996). Effect of a
professional practice model on perception of work group and satisfaction with
job. Journal of Nursing Administration (Annual Research Issue), 26(5), 1-9.
Ingersoll, G. L., Schultz, A. W., Hoffart, N., & Ryan, S. A. (1997). A longitudinal study
of the effect of a professional practice model on staff nurse satisfaction. In P. A.
Stamps (Ed.), Nurses and work satisfaction: An index for measurement (2nd ed.,
pp. 111-117). Chicago: Health Administration Press.
Ingersoll, G. L., Merk, S., Kirsch, J., Hepworth, J. T., Williams, M., & Wagner, L.
(2002). Patient focused redesign and employee perception of work environment.
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Kramer, M., & Schmalenberg, C.E. (2003). Magnet hospital staff nurses describe clinical
autonomy. Nursing Outlook, 51, 13-19.
Laschinger, H.K.S., Shamian, J., & Thomson, D. (2001). Impact of magnet hospital
characteristics on nurses’ perceptions of trust, burnout, quality of care, and work
satisfaction. Nursing Economics, 19, 209-219.
McClure, M., Poulin, M., & Sovie, M.D. (1983). Magnet hospitals: Attraction and
retention of professional nurses. Kansas City, MO: American Academy of
Nurses.
Mick, D. J., & Ackerman, M. H. (2000). Advanced practice nursing role delineation in
acute and critical care: Application of the Strong Model of Advanced Practice.
Heart & Lung, 29, 211-221.
Pasmore, W. A. (1988). Designing effective organizations. The sociotechnical systems
perspective. New York: John Wiley & Sons.
Senge, P.M. (1990). The fifth discipline. The art & practice of the learning organization.
New York: Doubleday Currency.
© Strong Memorial Hospital, Department of Nursing Practice