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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


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


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.


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.


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.


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