using a high-performance planning model to increase levels

Using a High-Performance PlanningModel to Increase Levels ofFunctional Effectiveness WithinProfessional Development

Peggi Winter, DNP(c), MA, RN, NE-BC

Nursing professional practice models continue to shape

how we practice nursing by putting families and members

at the heart of everything we do. Faced with enormous

challenges around healthcare reform, models create

frameworks for practice by unifying, uniting, and guiding

our nurses. The Kaiser Permanente Practice model was

developed to ensure consistency for nursing practice across

the continuum. Four key pillars support this practice model

and the work of nursing: quality and safety, leadership,

professional development, and research/evidence-based

practice. These four pillars form the foundation that makes

transformational practice possible and aligns nursing with

Kaiser Permanente’s mission. The purpose of this article is to

discuss the pillar of professional development and the

components of the Nursing Professional Development:

Scope and Standards of Practice model (American Nurses

Association & National Nursing Staff Development

Organization, 2010) and place them in a five-level development

framework. This process allowed us to identify the current

organizational level of practice, prioritize each nursing

professional development component, and design an

operational strategy tomove nursing professional development

toward a level of high performance. This process is suggested

for nursing professional development specialists.

Nursing professional practice models continue toshape how we practice nursing. Faced with enor-mous challenges from healthcare reform and

rapidly changing technology, it is essential to create frame-works for practice to unify, unite, and guide our nursing

workforce. The Kaiser Permanente Practice model was de-veloped in 2008, and continues to ensure consistency fornursing practice across the continuum. This frameworkguides our nurses as they provide quality care, collaboratewith interdisciplinary work teams, and contribute to theprofession of nursing. The Kaiser Permanente Nursingmodel is designed to standardize and move nursing prac-tice forward, and is the framework within which nursingtheories can be practiced. There are four key pillars in themodel, which support and organize our practice and thework of nursing: quality and safety, leadership, professionaldevelopment, and research/evidence-based practice.Within the work of these four pillars, we strive to establishpractices, processes, and systems throughwhich our visionis achieved. It becomes the foundation by which transfor-mational practice is possible and aligns nursing with KaiserPermanente’s mission.

The purpose of this article is to show how using theframework of the High-Performance Programming (HPP)model (Nelson & Burns, 2005) along with components ofthe Nursing Professional Development Specialist Practice(NPDSP)model (AmericanNursesAssociation [ANA]&Na-tional Nursing Staff Development Organization [NNSDO],2010) can be used to design a strategy for nursing profes-sional development. This process allows us to identify thecurrent organizational level of practice within nursing pro-fessional development, prioritize each component, anddesign an operational strategy to move professional devel-opment toward a higher-performing level. This processwas used at a 2-day event, where the regional directors ofeducation in all seven regions of the organization were rep-resented. During this event, the directors were asked todefine the components within the NPDSP model and com-pare to theHPPmodel levels. Each component was definedaccording to the NPDSP model in contrast to the levels ofthe framework. Consensus was reached within each leveland provided the foundation for movement to the next.

HPP ModelNelson and Burns’ framework, High-Performing Program-ming (HPP) model, assists in organizational evaluation,

Peggi Winter, DNP(c), MA, RN, NE-BC, is Director of National Educa-tion and Professional Development at National Patient Care Services,Kaiser Permanente, Oakland, California.

The author has disclosed that she has no significant relationships with, orfinancial interest in, any commercial companies pertaining to this article.

ADDRESSFORCORRESPONDENCE:PeggiWinter,DNP(c),MA,RN,NE-BC,National Education and Professional Development, National Patient CareService, Kaiser Permanente, 1800 Harrison St., 17th Floor, Oakland, CA94610 (e<mail: [email protected]).

DOI: 10.1097/NND.0000000000000204

Journal for Nurses in Professional Development www.jnpdonline.com 1

JNPD Journal for Nurses in Professional Development & Volume 00, Number 0, XYX & Copyright B 2015 Wolters Kluwer Health, Inc. All rights reserved.

forming a vision, and creating environments that movethe process to the next developmental level (Nelson &Burns, 2005). This model is part of a larger body of work,Transforming Work (Adams, 2005), which explores theconcept of transformational change and identifies asso-ciated principles, dynamics, and technologies. Adams movesthe conversation from the traditional practice of ‘‘Organi-zational Development’’ to ‘‘Organizational Transformation.’’Understanding and acknowledging the different perfor-mance levels helps organizations recognize the currentstate of performance and engenders an opportunity to cre-ate action steps to advance to the next level (Adams, 2005).This framework addresses the culture of an organizationand how leaders can modify their frame of reference tosupport change. These levels can be applied to individuals,the organization, or to specificwork units (Wolf, Finlayson,Hayden, Hoolahan, & Mazzoccoli, 2014). Another frame-work component discusses ways in which we adapt tochanges arising from the dynamic nature of the environmentswithinandexternal tohealth care.Change is inevitable; tomeetthe needs of our patients and the healthcare system,we caneither embrace and influence the changeor passively allowit to evolve. The HPPmodel encompasses four developmen-tal levels: reactive, responsive, proactive, progressive, andhighperforming. Themodel is a nestedmodel inwhicheachlevel builds on lower ones, except for the reactive level,which is disintegrative in nature and is unable to provide astructure to support culture change (Nelson & Burns, 2005).The Southern California region of Kaiser Permanente, recog-nizing its current state at a transitional level betweenproactiveand high performance, developed the progressive or proac-tive plus level to address a perceived gap between these twolevels in the HPP model framework. It lies between the pro-active and high-performing levels and was designed to callout a process or incident that might propel the componenttoward the high-performing level (see Figure 1).

DEVELOPMENT LEVELSReactive LevelThe reactive organization is one of survival and operatingin the past. It is characterized by affixing blame, force-fedcommunication, top-down leadership, and fragmented in-frastructure (Nelson & Burns, 2005). There is little owner-ship by staff who feels the organization is responsible fortheir practice. The staff sees the strategic direction of theorganization as management’s role. The environment ofprofessional development is paper- and classroom-based,face-to-face, and prescriptive. It is teacher driven andrewarded for volume, not value. Professional developmentmay appear to be content-rich but is low in interactivity,heavily reliant on slides and scripted presentations. Educa-tors’ tolerance for and ability to change is limited, and theirapproaches may be characterized by rigidity. Technology

is paper based and checklist driven. Duplicate programsand unconnected systems are the norm. The educator roleis directive, pedagogical, maternal, and codependent. It istask oriented, educator focused, and linear. The role of theeducator is as a performer or someone who finds gratifica-tion in delivering monologues.

Responsive LevelThe responsive organization is operating in the presentwith a hierarchical structure and a leadership style ofcoaching. It is focused on near-term goals and motivateswith rewards, which leadership helps to develop and im-plement (Nelson & Burns, 2005). The responsive organi-zation is characterized by cohesive teamwork and theability to adapt to solve problems. In this environment,themanager still ownsmost issues based on needs that lackclarity and are not necessarily aligned. Learners are passiveand feel no ownership for their continued education. UsingWeb-based training engenders the possibility of more flex-ible and fluid change. Technology that supports learning ismore connected, possibly including a learning manage-ment system that is resource intensive. Educators’ successis measured by the ability of learners to perform tasks orskills. Educators become more interested in the practiceof learning. Their role focuses on managing the educationexchange. The responsive stage of performance is comfort-able for individuals in the organization and may feel likethis is an acceptable place to remain.

Proactive LevelProactive organizations are future oriented. They are stra-tegic, goal oriented, and focused on the greater good andresults; emphasis on the bottom line decreases. Organiza-tional structure is matrix, and leaders have trust andmutualrespect for each other. Learners take responsibility for theirown success (Nelson & Burns, 2005). The environment ofprofessional development has less variety for learning, butit is more intentional and incorporates more coordinatedlearning solutions, which include follow-up and follow-through. Clinical support is actively present at the pointof care. There are standard competencies for the role ofthe nurse, and other competencies are connected to prac-tice workflow. Educators’ success is measured by learners’ability to apply the skill. Learning is consultative, and theeducator role is one of facilitator and coach.

Progressive Level (Proactive Plus)Quantitative and qualitative performance scores reflect value-driven professional nursing practice. The organization is oncourse toward global holistic high standards of excellence.Universal buy-in exists and is embedded in the culture. In thislevel, theremight be an incident that propels the organizationto the high-performing level. This could be the adoption of anew model, a culture change, or a new leadership focus.

2 www.jnpdonline.com Month 2015

FIGURE 1 Adapted for Kaiser Permanentewith permission fromNelson&BurnsHigh PerformanceProgrammingModel (2005). http://tinyurl.com/qammupq.


FIGURE 1 (Continued)


High-Performing LevelHigh-performing work achieves high standards of excel-lence. The organizational focus is on excellence, seekingout new opportunities for excellence, and releasing theflow of energy necessary for accomplishing these innova-tions (Nelson & Burns, 2005). Professional development isembedded in the work, and all parties are engaged. Own-ership and accountability makes it easier to do the rightthing. Learning is shared among team members, and thereis an explicit and coherent message around quality, met-rics, improved communication, and ongoing evaluation.The environment is dynamic, integrated, and linked tobusiness success. Immediate real-time data and feedbackare designed with patient input. The role of educators isto manage complexity, and they are master facilitators oflearning that is focused on business outcomes, perfor-mance, and organizational objectives. Learning is valuedas an end unto itself and transforms practice to excellence.

Educators function as coaches and are characterized byrich and integrative dialogue, creativity, and wisdom.

NPDSP ModelIn 2010, a new approach and elements were formulated byNNSDO to design a model to operationalize a professionaldevelopment system composed of inputs, throughputs,and outputs (see Figure 2). Inputs are defined as whatthe learner and the educator bring to the process. Learnersbring their beliefs, attributes, experience, educational level,career goals, engagement, and empowerment. Educatorscollaborate across the organization, assess organizationalneeds, and facilitate continuous learning based on devel-opmental processes (throughputs). According to the NursingProfessional Development: Scope and Standards of Practice(ANA & NNSDO, 2010), seven developmental processes,guided by the model of care and the professional practicemodel, are intended to operationalize the role of the learner

FIGURE 2 Nursing Professional Development Specialist Practice Model 2010 (used with Permission).


in a developmental and lifelong learning process. Thesethroughput processes are competency programs, continu-ing education, academic partnership, orientation, careerdevelopment/role transition, research and scholarship, andinservice education. All are grounded in evidence-basedpractice and practice-based evidence. Outputs are growthand professional role competence. Arrows indicate themodel’s fluidity and interrelationships between elements.The NPDSP model is a foundational pathway to helpnurses in professional development guide their practice.Applying the HPP model (Nelson & Burns, 2005) to devel-opmental processes or core componentsof theNPDSPmodelprovides aprocess for assessing the current state and develop-ing strategies to evolve to the next stage, with the ultimategoal of high performance.

Applying the HPP Model to Components of theNPDSP Model

OrientationOrientation is defined as the process of introducing a nurseto goals, policies, procedures, and role expectations neededto function in a new or unfamiliar environment. It can beorientation to a job, a role transition, or a facility (ANA &NNSDO, 2010). The duration of orientation can be a fewdays, weeks, or even months. At the reactive level, orien-tations are diffuse and leadership enforces topics. Deci-sions about orientation length are driven only by budgetor staffing needs. Educators and staff within each region,facility, or unit feel their orientation is themost critical to pre-pare the nurse, and they are unable or unwilling to collabo-rate. Content organization and evaluation processes areinconsistent. Ownership is leadership driven, and any newinitiative is placed as a topic in orientation. New initiativesare usually crisis driven and task oriented. Checklists, forms,mandatory requirements, and compliance drive orientation.

At the responsive level, orientations are thought of as build-ing processes. Leadership and human resources share own-ership. This is amaternal environment inwhich nurses feel theyarebeingcared for,andfailure restsmorewith theeducator thanwith the rest of the team. Educators have a role in orientationbutmaynot be involved indiscussions impacting theprogram.

At the proactive level, onboarding is more strategic, andownership is clearly shared between leaders, staff, and theorientee. Expected outcomes are clearer, and employeeshave more accountability and ownership. Preceptor, newemployee, andmanager complete the evaluation of the ori-entation process. Preceptors are engaged and feel ac-countable for a positive experience and outcomes. Duringorientation, the orientee receives structured feedback.

At the progressive level, we might see the use of unit-based teams or a multidisciplinary team. There may be acultural change about ‘‘owning’’ the success of each newemployee. This may also be a time when technology is

helping to supplement and contribute to the orientation ex-perience with the use of the electronic medical record,learning management systems, or smart phones.

At the high-performing level,multidisciplinary onboard-ing occurs with members of the healthcare team. Team-building activities, engagement, and socialization are morefrequent. The orientee owns anddrives the orientation pro-cess. Evaluation is a 360-degree process and the orientee’sperspectives and ideas and the healthcare teamvalue inno-vations. Orientation is all about, ‘‘you and your profes-sional nursing practice.’’

CompetenciesCompetencies are defined as processes that are used todemonstrate the knowledge, skills, and attitudes necessaryto perform a job and daily activities necessary for the ben-efit of the population being served (ANA&NNSDO, 2010).At the reactive level, only clinical skills are considered to becompetencies, and there is no organization-wide accepteddefinition of competencies. They are added to nursing practicewithout outcomes in place and continue to be added annu-ally without justification for their continuation. Primarilynew initiatives and vendor products determine competen-cies; staff has no involvement in determining or designingthem. Educators are responsible for the completion by staffof competencies.

At the responsive level, competencies are developed toachieve goals and plan for the present work. Data are col-lected but not used, except ad hoc or for regulatory pur-poses. At the proactive level, multiple ways exist to validatecompetencies. Staff is engagedwith developing competen-cies as a team, and ownership belongs to both individualsand the team. An appropriate competency verificationmethod is selected, and everyone on the team knows theirrole in meeting the defined competencies. At the progres-sive level, personal portfolios are introduced to the staff,and the definition of competent is at a higher domain thanskill based. At the high-performing level, a professionalcompetency portfolio exists that interdisciplinary teamsvalidate. Patient outcomes define competency levels ofthe team, and the electronic medical record is another toolused to validate individual and team performance.

Academic partnershipsAcademic partnerships are agreements between colleges/schools of nursing and healthcare systems to support anenvironment of development and continuous learning(ANA & NNSDO, 2010). At the reactive level, academicpartnerships are thought of as clinical agreements, andthere is increased criticism about the level of newgraduatesand their skills. Education is perceived as ameans to an endwith no clear roadmap for attaining the next level. At thislevel, the world of clinical practice is not integrated withacademic learning’s.


At the responsive level, academic partnerships serve toanswer the present need of the organization. Competen-cies revolve around skills required for the new graduateto gain employment. Preceptors and students work togetherpassively. Preceptors are happy to participate, but do notactively assist in the knowledge of the student nurse. Aspartnerships move to the proactive level, nursing practicebegins to influence the curriculum. A residency program isin place to transition the new graduate to the practice en-vironment. Formal mentoring with staff occurs, and theorganization brings new graduates into the ambulatory set-ting, helping to shape the nurse of the future.

At the progressive level, formal mentoring is in place for thestudent prior to graduation. Transition-to-Practice Programsare in place to ensure that newly licensed nurses are affordedtheopportunity togainconfidenceandcompetenceas theyen-ter theworkforce, thus enhancing patient safety and increasingretention in the workplace. Staff nurses are affiliate faculty andassist with teaching and designing the curriculum.

At high-performing levels, competencies are agreed uponby academia andpractice, and built into the curriculumandinto orientation. Members of other disciplines on the teamprovide feedback, and clinical experiences are designedacross the continuum of care. Accountability and owner-ship lines are blurred between academia and practice,and academic and clinical staff alike feel comfortable inboth environments.

Continuing educationContinuing education is defined as learning activitiesdesigned to augment knowledge, skills, and attitudes ofthe nurse, which they apply to their practice (ANA &NNSDO, 2010). At the reactive level, continuing educationis prescriptive and lacks outcomemeasures. It is thought ofas an individual activity, so outcome measures are unnec-essary. Education is perceived of as a means to an end orthe number of continuing education units necessary to re-new a license. At the responsive level, continuing edu-cation is the reward for achievement of the course orcontent. Although outcomes are measured, they areunrelated to changes in practice or patient outcomes. Atthe proactive level, journal clubs form and staff volunteersto assist as subject matter experts for programs. Learningobjectives are tied to patient outcomes and are long term innature, rather than related to completion of the educationalmaterial. Nurses incorporate changes to their practice in theirprofessional portfolio. At the progressive level, learning ob-jectives from continuing education are expected to be tied topatient outcomes and incorporated into their professionalportfolio to demonstrate how this has changed their practice.

At the high-performing level, nurses build a businesscase for a change in infrastructure that tracks educationaltime and links nursing professional development, research,and technology.

Career development/role transitionCareer development/role transition involves the identifica-tion and development of a strategy to assist an individual inmappingout a career changeor expansion (ANA&NNSDO,2010). At the reactive level, career development/role transi-tion is left up to the individual, with no guidance or roadmapfor assistance. Minimal organizational support exists forrole advancement, and staff does not value advancementor professional growth. At the responsive level, career de-velopment processes are consistent and can be tailored byindividuals with some integration. Organizational supportexists in the form of tuition reimbursement or loans foradvancing knowledge and skills. Staff participates becauseof management expectations or because career develop-ment is part of a job description. At the proactive level,integrated role transition occurs, and the team is responsi-ble for talent initiatives. Staff is self-aware of developmentneeds and begins to own and organize professional devel-opment activities. Staff at this level is committed to thedevelopment of their peers through mentoring activities.At the proactive level, programs or processes are in placeto encourage certification. This might be done through cel-ebrations, monetary rewards, and visible leadershipsupport. At the high-performing level, talent managementis business driven. Nurses drive change based on their ac-quired knowledge and align their development goals to theorganization’s strategic plans. Career coaching begins inorientation and is integrated into new roles that are evolv-ing because of the changing healthcare environment.

Research and scholarshipNursing research is a systematic process to question orsolve problems in order to expand nursing knowledge.Scholarship is being inquisitive aboutwhatworks andwhatdoes not, measuring outcomes, conducting peer review,andpublishing (ANA&NNSDO, 2010). At the reactive level,research and scholarship are not parts of nursing practiceand education is not valued or supported. Tuition reim-bursement is not perceived to be as a strategy tool; instead,‘‘one size fits all.’’ Certification is not encouraged or valued,and research is siloed with little connection to actual prac-tice. At the responsive level, work is in progress to have amore highly educated workforce. Tuition reimbursementaligns with career development and business strategies.At the proactive level, tuition assistance is leveraged in sup-port of employee development goals. ‘‘Best practices’’ areacknowledged and celebrated, and the baccalaureate de-gree is the entry level for all nurses. Specialty certification isan expectation, and research is conducted in the practiceenvironment as an interdisciplinary team and as part ofan annual portfolio. In the progressive level, staff commitsto self-development and the development of their peers. Atthe high-performing level, customdegree programs are de-veloped and delivered. Master’s and doctoral programs are


part of the practice role, and publishing is part of the role ofa staff nurse.

Inservice educationInservice education is defined as training provided in thework setting for the purpose of assisting nurses in per-forming their assigned functions in a specific workplace(ANA&NNSDO,2010). In the reactive level, inservice isownedby the education or training department. It is force-fed anddictated by leadership. Attendance is mandatory, andinservices are seen as theway to solvemanagement issues.‘‘Just send them to training and it will fix the problem.’’ Atthe responsive level, inservice education is tied to specificoutcomes. There are rewards associated with attendance,and training is around activities in the present. Structure istop-down, and evaluations are level 1. At the proactive level,inservices are result driven and part of the overall strategyof the unit or department. The information provided is ac-complished in partnership with staff and linked to qualityand safety goals. At the progressive level, we see learningcommunities being built. At high-performing levels, we areinvolving all stakeholders in the planning and design.Technology assists with training at the point of care, andadult-oriented models of active learning is the inserviceprogram design.

SUMMARY, CONCLUSION, AND NEXT STEPSCombining a development model with the seven compo-nents of the NPDSPmodel (ANA&NNSDO, 2010) enables

assessment of the current level of each component, and thedevelopment of an operational strategy to move towardthe ultimate goal of attaining and sustaining high-level per-formance. Within a complex integrative system, such asKaiser Permanente, levels are always evolving andmovingas standards and practices change. The model will beupdated annually by the regional executives to maintainconsensus between the seven regions and celebrate oursuccesses while we strategize for the future. The culture ofan organization either hinders or supports acceleration inchange and the flexibility to adapt (Nelson & Burns, 2005).Consequently, the process described here is invaluable toevaluating and changing componentswithin an organizationalculture that inhibit movement to a high-performing level insupport of a professional practice model.

ReferencesAdams, J. D. (2005). Transforming work (2nd ed.). New York, NY:

Miles River Press.American Nurses Association (ANA) & National Nursing Staff De-

velopment Organization (NNSDO). (2010). Nursing professionaldevelopment: Scope and standards of practice. Silver Spring,MD: American Nurses Publishing, NurseBooks.org.

Nelson, T., & Burns, F. (2005). High performance programming: aframework for transforming organizations. In Adams J. (Ed.),Transforming work (2nd ed., pp. 262Y281). New York, NY: Cosimo.

Wolf, G., Finlayson, S., Hayden, M., Hoolahan, S., & Mazzoccoli, A.(2014). The developmental levels in achieving Magnet des-ignation, Part 1. The Journal of Nursing Administration, 44(3),136Y141. http://dx.doi.org/10.1097/NNA.0000000000000041


using a high-performance planning model to increase levels

Documents