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Hughes RG, editor. Patient Safety and Quality: An Evidence-Based Handbook for Nurses. Rockville (MD): Agency for Healthcare Research and Quality (US); 2008 Apr.

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Patient Safety and Quality: An Evidence-Based Handbook for Nurses.

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Chapter 19Care Models

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Bonnie M. Jennings, D.N.Sc., R.N., F.A.A.N., colonel, U.S. Army (Retired), and health care consultant; e-mail: ten.xoc@sgninnejmb

Background

The organization of care delivery is determined by a variety of factors such as economic issues, leadership beliefs, and the ability to recruit and retain staff. Ideally, evidence of the effect of care models on quality and patient safety would also be a major factor in decisionmaking.

Historically, four traditional care models have dominated the organization of inpatient nursing care. Functional and team nursing are task-oriented and use a mix of nursing personnel; total patient care and primary nursing are patient-oriented and rely on registered nurses (RNs) to deliver care.1, 2 In the late 1980s, a number of nontraditional nursing care delivery models emerged that use various mixes of licensed and unlicensed nursing personnel.3–5

Care models do not exclusively pertain to the organization of nursing care, however, or the inpatient setting. Models have been examined for medical housestaff,6 pharmacy services,7 and social workers.8 They have been considered for ambulatory care,9–12 home care,13–15 and nursing homes.16 Care models also exist for specific patient populations such as elderly patients,17–20 people with mental health needs,21 and individuals with chronic conditions22 to include disease management models23, 24 and the use of technology.25

Research Evidence

Despite the interest in a variety of care models, it is difficult to discern which models work best. Neither the traditional nor the nontraditional inpatient nursing care models have been evaluated rigorously for their effects on patient safety.2, 4, 26 Emerging models from other care disciplines, other settings, and particular patient populations are also lacking rigorous empirical assessments of their relationship to patient safety.

A number of investigations examining care models addressed nurses’ perceptions of the care model.1, 27–38 Only two investigations combined the nurses’ perceptions with patient safety measures.39, 40

Several studies did not meet the criteria for inclusion in this review, largely due to weak designs. Of these, some reported pilot data,6, 7, 13, 24, 41, 42 some were quality-improvement projects,14, 17, 43 and others used qualitative methods.32, 36,44–48 Like the quantitative studies, the rigor of the qualitative investigations varied. However, these qualitative studies illuminate important aspects of care models not evident in quantitative investigations. For example, Ingersoll32 and Redman and Jones36 were among the first investigators to assess the effects of patient-centered care models on nurse managers. The data from both of these studies expose the pressure and role confusion experienced by nurse managers. Subsequently, a quantitative investigation found nurse managers experienced a high level of emotional exhaustion, a key component of burnout.49

Among the quantitative studies of care models included in the evidence table, only one used a design that combined systematic review and meta-analytic techniques.23 No randomized controlled trials were identified. The remaining seven studies used Level 3 designs. In two of these studies, large databases were used to examine different care models for home-based long-term care15 and mental health services.21

All five studies of nursing care models meeting inclusion criteria focused on acute care work redesigns in which the mix of nursing personnel was altered in some way. For each of these five investigations, data were reported from only one hospital.39, 40, 50–52 Of these studies, one evaluated changes in care delivery models at one university teaching hospital with two campuses in the same city.39 The remaining studies were smaller in scale focusing data collection on one,50, 51 two,52 or three units40 in the same facility. Most often, measurements were done at three points in time—pre-implementation, and at 6 and 12 months after the model was introduced.39, 40, 52

Evidence-Based Practice Implications

The eight studies in Table 1 illustrate two main clusters of research. The first pertains to studies of inpatient nursing care models. Statistically discernible differences were rarely evident, and when they were, there was no clear pattern to guide practice.39, 40, 50–52 For example, there were statistically fewer falls reported in two studies after units implemented care models using fewer RNs, presumably because there were more staff to assist patients.50, 51 Fewer medication errors were detected in only two reports.39, 52 However, quite unexpectedly and counter intuitively, postoperative pain scores were statistically higher on a unit after the number of RNs increased.50

Table 1

Table 1

Evidence Table for Care Models

There were no consistent patterns visible in findings among the studies that followed changes in the care model over time—before implementation and at 6 and 12 months.39, 40, 52 However, the studies with multiple measurements showed that initial indicators of success were rarely sustained over time. This is similar to results from the study by Greenberg and colleagues21 in which most positive effects of change lasted only one year. Despite the growing number of work redesign studies, the findings are too disparate even among those with stronger designs to offer a clear direction about practice changes to improve patient safety.

The second cluster of care model studies consists of three investigations that were conducted by other disciplines.15, 21, 23 These studies demonstrate that the interest in determining which care models operate best is not isolated to nursing. The improved ability to detect statistical differences in these models may derive from their large sample sizes, their statistical techniques, or their use of different outcomes. The systematic review and meta-analysis of disease management programs for individuals with depression offers the strongest evidence for guiding care delivery.23 With only one study of consumer-directed home-based long-term care,15 and one of service-line delivery of mental health services,21 practice changes for these areas should be considered carefully.

Research Implications

We actually know very little about the relationship between care models and patient safety. Randomized controlled trials (RCTs) might contribute evidence that would help investigators, administrators, and policy makers sort through the confusion. RCTs would be particularly difficult to conduct, however, given the need to have longitudinal data. The rapidly changing health care environment is not conducive to such endeavors.

The most glaring need relates to clarifying the work that needs to be done for patients and then determining which clinicians are best suited to provide it. Looking only at the work of nurses, which has dominated studies of care models in acute care settings, fails to consider nonnursing staff who are critical to the patient care mission.

We also know very little about care models that promote patient safety in outpatient settings, home care, or long-term care. These are areas that remain to be explored.

Conclusion

Care delivery models range from traditional forms, such as team and primary nursing, to emerging models. Even models with the same name may be operationalized in very different ways. The rationale for selecting different care models ranges from economic considerations to the availability of staff. What is glaring in its absence, however, is the limited research related to care models. Even more sparse is research that examines the relationship between models of care and patient safety. Ideally, future studies will not only fill this void, but the models tested will be developed based on a comprehensive view of patient needs, taking the full complement of individuals required to render quality care into account.

Search Strategy

Both MEDLINE® and CINAHL® databases were searched from 1995 to 2005 to identify research-based articles published in the English language that were pertinent to this review. Search terms were identified with the guidance of a reference librarian. The term “care models” was not a search option in CINAHL®. Therefore the CINAHL® search terms included “care delivery modules,” “nursing care delivery systems,” and “care modules.” The MEDLINE® search was based on two terms, “care models” and “organizational models.” Together, these searches yielded 549 citations, 55 in CINAHL® and 494 in MEDLINE®.

The abstracts for each of the 549 citations were reviewed. From this assessment it was determined that 82 of the articles were sufficiently focused on nursing or patient care models and should be considered further. Most of the 467 papers that were omitted used the word “model” in their title, but the work was not related to care models per se. For example, articles about medical management models were not used in this review. Additionally, a number of papers addressed topics with no discernible connection to care models (e.g., life support decisions for extremely premature infants).

The 82 articles were located and carefully read. As a result, 31 additional papers were omitted from the actual analysis. Reasons for these omissions included the lack of sufficient detail about the study, duplicate publications, and studies of advanced practice nurses. This left 51 articles for consideration in this review.

Acknowledgments

Tremendous gratitude is expressed to the staff of the Armed Forces Medical Library for their considerable support of this work. They conducted the database searches and assisted in acquiring numerous papers considered in this review.

References

1.
Adams A, Bond S, Hale CA. Nursing organizational practice and its relationship with other features of ward organization and job satisfaction. J Adv Nurs. 1998;27:1212–22. [PubMed: 9663873]
2.
Tiedeman ME, Lookinland S. Traditional models of care delivery. What have we learned? J Nurs Adm. 2004;34(6):291–7. [PubMed: 15190224]
3.
Hall LM. Staff mix models: complementary or substitution roles for nurses. Nurs Admin Q. 1997;21(2):31–9. [PubMed: 9069950]
4.
Hoover KW. Nursing work redesign in response to managed care. J Nurs Admin. 1998;28(11):9–18. [PubMed: 9824979]
5.
Lookinland S, Tiedeman ME, Crosson AET. Nontraditional models of care delivery. Have they solved the problems? J Nurs Adm. 2005;35(2):74–80. [PubMed: 15714099]
6.
Afessa B, Kennedy CC, Clarich KW, et al. Introduction of a 14-hour work shift model for housestaff in the Medical ICU. Chest. 2005;128:3910–5. [PubMed: 16354863]
7.
Crowson K, Collette D, Dang M, et al. Transformation of a pharmacy department: impact on pharmacist interventions, error prevention, and cost. Jt Comm J Qual Improv. 2002;28:324–30. [PubMed: 12066624]
8.
Gathercole MF, DeMello LR. Development of the workload analysis scale (WAS) for the assessment and rehabilitation services of Ballarat Health Services. Soc Work Health Care. 2001;34(1–2):143–60. [PubMed: 12219764]
9.
Aita V, Dodendorf DM, Lebsack JA, et al. Patient care staffing patterns and roles in community-based family practices J Fam Prac 2001. 50http://www​.jfponline.com. [PubMed: 11674893]
10.
Haas SA, Hackbarth DP. Dimensions of the staff nurse role in ambulatory care: part III: using research data to design new models of nursing care delivery. Nurs Econ. 1995;13:230–41. [PubMed: 7630444]
11.
Hackbarth DP, Haas SA, Kavanagh JA, et al. Dimensions of the staff nurse role in ambulatory care: part I: methodology and analysis of data on current staff nurse practice. Nurs Econ. 1995;13:89–98. [PubMed: 7760963]
12.
Tackett J, Maciejewski ML, Richardson RD, et al. Prediction costs of Veterans Affairs health care in Gulf War veterans with medically unexplained physical symptoms. Mil Med. 2005;170:70–5. [PubMed: 15724858]
13.
Badovinac CC, Wilson S, Woodhouse D. The use of unlicensed assistive personnel and selected outcome indications. Nurs Econ. 1999;17:194–200. [PubMed: 10711162]
14.
Baker DI, Gottschalk M, Eng C, et al. The design and implementation of a restorative care model for home care. Gerontologist. 2001;42:257–63. [PubMed: 11327492]
15.
Benjamin AE, Matthias R, Franke TM. Comparing consumer-directed and agency models for providing supportive services at home. Health Serv Res. 2000;35(1, Part II):351–66. [PMC free article: PMC1089106] [PubMed: 10778820]
16.
Finnema E, deLange J, Droes R, et al. The quality of nursing home care: do the opinions of family members change after implementation of emotion-oriented care? J Adv Nurs. 2001;35:728–40. [PubMed: 11529975]
17.
Fitzpatrick J, Stier L, Eichorn A, et al. Hospitalized elders: changes in functional and mental status. Outcomes Manage. 2004;8(1):52–6. [PubMed: 14740585]
18.
Fulmer T, Mezey M, Bottrell M, et al. Nurses improving care for healthsystem elders (NICHE): Using outcomes and benchmarks for evidence-based practice. Geriatric Nurs. 2002;23:121–7. [PubMed: 12075275]
19.
Mezey M, Firpo A, Kobayashi M, et al. Nurses improving care to health system elders (NICHE). Implementation of best practice models. J Nurs Adm. 2004;34(10):451–7. [PubMed: 15577667]
20.
Turner JT, Lee V, Fletcher K, et al. Measuring quality of care with an inpatient elderly population. The geriatric resource nurse model. J Gerontological Nurs. 2001;27:8–18. [PubMed: 11915260]
21.
Greenberg GA, Rosenheck RA, Charns MP. From profession-based leadership to service line management in the Veterans Health Administration. Med Care. 2003;41:1013–23. [PubMed: 12972841]
22.
Glasgow RE, Wagner EH, Schaefer J, et al. Development and validation of the patient assessment of chronic illness care (PACIC) Med Care. 2005;43:436–44. [PubMed: 15838407]
23.
Neumeyer-Gromen A, Lampert T, Stark K, et al. Disease management programs for depression. A systematic review and meta-analysis of randomized controlled trials. Med Care. 2004;42:1211–21. [PubMed: 15550801]
24.
Solberg LI, Reger LA, Pearson TL, et al. Using continuous quality improvement to improve diabetes care in populations: the IDEAL model. Jt Comm J Qual Improv. 1997;23:581–92. [PubMed: 9407262]
25.
Jerant AF, Azari R, Martinez C, et al. A randomized trial of telenursing to reduce hospitalization for heart failure: patient-centered outcomes and nursing indicators. Home Health Care Serv Q. 2003;22:1–20. [PubMed: 12749524]
26.
Seago JA. Chapter 39 Nurse staffing, models of care delivery, and interventions. Making health care safer: a critical analysis of patient safety practices. In: Shojania KG, Duncan BW, McDonald KM, et al., editors. Evidence Report/Technology Assessment No 43 Pub No01-E058. Rockville, MD: Agency for Healthcare Research and Quality; 2002. pp. 427–33.
27.
Adams A, Bond S. Clinical specialty and organizational features of acute hospital wards. J Adv Nurs. 1997;26:1158–67. [PubMed: 9429966]
28.
Cone M, McGovern CC, Barnard K, et al. Satisfaction with a new model of professional practice in critical care. Crit Care Nurs Q. 1995;18(3):67–74. [PubMed: 7584312]
29.
Edgar L. Nurses’ motivation and its relationship to the characteristics of nursing care delivery systems: a test of the job characteristics model. Can J Nurs Leadersh. 1999;12:14–22. [PubMed: 11087194]
30.
Hall LM, Doran D. Nurse staffing, care delivery model, and patient care quality. J Nurs Care Qual. 2004;19:27–33. [PubMed: 14717145]
31.
Hastings C. Differences in professional practice model outcomes: The impact of practice setting. Crit Care Nurs Q. 1995;18:75–86. [PubMed: 7584314]
32.
Ingersoll GL, Cook J, Fogel S, et al. The effect of a patient-focused redesign on midlevel nurse managers’ role responsibilities and work environment. J Nurs Adm. 1999;29(5):21–7. [PubMed: 10333858]
33.
Laschinger HKS, Finegan J, Shamian J, et al. Organizational trust and empowerment in restructured healthcare settings. Effects on staff nurse commitment. J Nurs Admin. 2000;30(9):413–25. [PubMed: 11006783]
34.
Makinen A, Kivimaki M, Elovainio M, et al. Organization of nursing care and stressful work characteristics. J Adv Nurs. 2003;43:197–205. [PubMed: 12834378]
35.
McLaughlin FE, Thomas AS, Barter M. Changes related to care delivery patterns. J Nurs Adm. 1995;25(5):35–46. [PubMed: 7730932]
36.
Redman RW, Jones KR. Effects of implementing patient-centered care models on nurse and non-nurse managers. J Nurs Adm. 1998;28(11):46–53. [PubMed: 9824985]
37.
Salmond SW. Models of care using unlicensed assistive personnel. Part I: job scope, preparation and utilization patterns. Orthopaedic Nurs. 1995;14(5):20–30. [PubMed: 7567081]
38.
Salmond SW. Models of care using unlicensed assistive personnel. Part II: perceived effectiveness. Orthopaedic Nurs. 1995;14(6):47–58. [PubMed: 8700569]
39.
Seago JA. Evaluation of a hospital work redesign. Patient-focused care. J Nurs Adm. 1999;29(11):31–8. [PubMed: 10565318]
40.
Tourangeau AE, White P, Scott J, et al. Evaluation of a partnership model of care delivery involving registered nurses and unlicensed assistive personnel. Can J Nurs Leadersh. 1999;12(2):4–20. [PubMed: 11094929]
41.
Clark JS. An aging population with chronic disease compels new delivery systems focused on new structures and practices. Nurs Admin Q. 2004;28(2):105–15. [PubMed: 15181676]
42.
Holcomb BR, Hoffart N, Fox MH. Defining and measuring nursing productivity: a concept analysis and pilot study. J Adv Nurs. 2002;38:378–86. [PubMed: 11985689]
43.
Nardone PL, Markie JW, Tolle S. Evaluating a nursing care delivery model using a quality improvement design. J Nurs Care Qual. 1995;10(1):70–84. [PubMed: 7579550]
44.
Beal JA. A nurse practitioner model of practice in the neonatal intensive care unit. Am J Maternal/Child Nurs. 2000;25(1):18–24. [PubMed: 10676081]
45.
Eilers J, Heermann JA, Wilson ME, et al. Independent nursing actions in cooperative care. Onc Nurs Forum. 2005;32:849–55. [PubMed: 15990914]
46.
Fitzgerald M, Pearson A, Walsh K, et al. Patterns of nursing: a review of nursing in a large metropolitan hospital. J Adv Nurs. 2003;12:326–32. [PubMed: 12709106]
47.
Waters KR, Easton N. Individualized care: is it possible to plan and carry out? J Adv Nurs. 1999;29:79–87. [PubMed: 10064285]
48.
Wiles R, Postle K, Steiner A, et al. Southampton NLU evaluation team. Nurse-led intermediate care: patients’ perceptions. Internatl J Nurs Studies. 2002;40:61–71. [PubMed: 12550151]
49.
Laschinger HK, Almost J, Purdy N, et al. Predictors of nurse managers’ health in Canadian restructured healthcare settings. Nurs Leadersh. 2004;17(4):88–105. [PubMed: 15656251]
50.
Barkell NP, Killinger KA, Schultz SD. The relationship between nurse staffing models and patient outcomes: a descriptive study. Outcomes Manage. 2002;6(1):27–33. [PubMed: 12500413]
51.
Grillo-Peck AM, Risner PB. The effect of a partnership model on quality and length of stay. Nurs Econ. 1995;13(6):367–74. [PubMed: 8538811]
52.
Heinemann D, Lengacher CA, VanCott ML, et al. Partners in patient care: measuring the effects on patient satisfaction and other quality indicators. Nurs Econ. 1996;14(5):276–85. [PubMed: 8998022]
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