module 4 essay

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E V I D E N C E S Y N T H E S I S

Models of care in nursing: a systematic reviewjbr_287 324..337

Ritin Fernandez RN MN (Critical Care) PhD,1,2 Maree Johnson RN BAppSci MAppSci PhD,3,4 Duong Thuy Tran BMed (Vietnam) MIPH (USyd)5 and Charmaine Miranda BPsycholgy6 1School of Nursing, Midwifery and Indigenous Health, University of Wollongong, Wollongong, 2Centre for Research in Nursing and Health, St George Hospital, Kogarah, 3Centre for Applied Nursing Research, Sydney South West Area Health Service, 4School of Nursing and Midwifery, University of Western Sydney, Sydney, 5School of Medicine, University of Western Sydney, Sydney, and 6Centre for Positive Psychology and Education, School of Education, University of Western Sydney, Sydney, New South Wales, Australia

Abstract Objective This review investigated the effect of the various models of nursing care delivery using the diverse levels of nurses on patient and nursing outcomes.

Methods All published studies that investigated patient and nursing outcomes were considered. Studies were included if the nursing delivery models only included nurses with varying skill levels. A literature search was performed using the following databases: Medline (1985–2011), CINAHL (1985–2011), EMBASE (1985 to current) and the Cochrane Controlled Studies Register (Issue 3, 2011 of Cochrane Library). In addition, the reference lists of relevant studies and conference proceedings were also scrutinised. Two reviewers independently assessed the eligibility of the studies for inclusion in the review, the methodological quality and extracted details of eligible studies. Data were analysed using the RevMan software (Nordic Cochrane Centre, Copenhagen, Denmark).

Results Fourteen studies were included in this review. The results reveal that implementation of the team nursing model of care resulted in significantly decreased incidence of medication errors and adverse intravenous outcomes, as well as lower pain scores among patients; however, there was no effect of this model of care on the incidence of falls. Wards that used a hybrid model demonstrated significant improvement in quality of patient care, but no difference in incidence of pressure areas or infection rates. There were no significant differences in nursing outcomes relating to role clarity, job satisfaction and nurse absenteeism rates between any of the models of care.

Conclusions Based on the available evidence, a predominance of team nursing within the comparisons is suggestive of its popularity. Patient outcomes, nurse satisfaction, absenteeism and role clarity/confusion did not differ across model comparisons. Little benefit was found within primary nursing comparisons and the cost effectiveness of team nursing over other models remains debatable. Nonetheless, team nursing does present a better model for inexperienced staff to develop, a key aspect in units where skill mix or experience is diverse.

Key words: evidence-based practice, nursing, systematic review.

Background

Various models for the delivery of nursing care such as patient allocation, primary nursing and team nursing have been implemented over the past few decades. These models performed successfully in the workforce that mainly con- sisted of registered nurses (RNs). However, over the past 10 years, the healthcare environment in Australia and globally

has undergone significant changes mainly due to shortages of RNs and budget constraint.1 As a result, a major restruc- ture of the nursing workforce has been undertaken2 includ- ing filling RN positions with enrolled nurses (ENs), assistants in nursing and unlicensed carers.3

This study sought to provide evidence of the effectiveness of the varying models of care used in nursing, in particular, team nursing (group of nurses caring for a large group of patients for one shift) and patient allocation (one nurse caring for a small number of patients for one shift). This review will inform health service policy on when and how to apply differing nursing models of care within practice.

Correspondence: Professor Ritin Fernandez, St George Hospital, Kogarah, NSW 2217, Australia. Email: ritin.fernandez@ sesiahs.health.nsw.gov.au

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doi:10.1111/j.1744-1609.2012.00287.x Int J Evid Based Healthc 2012; 10: 324–337

In Australia, the inclusion of the differing levels of nurses into the workforce has led to redefining the roles of RNs and ENs in order to maximise the resources during the shortage. For example, RNs have been given roles such as clinical supervision and ENs are permitted to administer medica- tions under the supervision of RNs. In some areas, ENs have extended roles including wound care.4

Several adaptations and combinations of the traditional models of patient care delivery have arisen in order to accommodate the changing roles of nurses and the various levels of nursing skill mix.5–8 These include team-oriented models such as partners in care9,10 shared care nursing,8,11

modular nursing and partners in practice.12,13 Evaluations of the various models of care delivery have demonstrated that a RN-predominant skill mix is associated with better patient health outcomes and lower mortality, improved quality of care and reduction in medication errors and wound infec- tions,14,15 which can be explained by RN’s ability to earlier detect patient deterioration and intervene timely.16 Other studies have found improvements in staff satisfaction, recruitment and retention of staff and reduction in sick leave, improved team spirit and a cleaner ward environment.17

Patient allocation models have also been implemented with the varying skill mix and in one study8 there was no difference in job satisfaction between a team-oriented model and patient allocation model. Communication between all members of nursing and interdisciplinary teams is believed to be a key element for the success of any care delivery models.18 In a study11 that compared a team-oriented and patient allocation model of care, there were no significant differences in communication at the 6-month follow up. One of the disadvantages of the patient allocation model in the current workforce is little capacity for supervising or teaching inexperienced new staff and the possibility of junior RNs and ENs being required to care for patients beyond their skills and experience.17

A recent report from the New South Wales Health follow- ing an inquiry into nursing services recommended the use of a team model for nursing care delivery.19 However, the deci- sion to change to a different model of care should be informed by existing evidence to support or refute the effi- cacy of the model. Although reviews have been previously undertaken evaluating the various models of care, these reviews have combined nursing care delivery models com- prising of all RNs (e.g., team nursing with all RNs and patient allocation with all RNs), as well as the various levels of nurse. In contemporary nursing practice, wards staffed with all RNs are fast becoming nonexistent.1 Therefore, the aim of this study is to undertake a systematic review of the literature to investigate the effect of the various models of nursing care delivery using the diverse levels of nurses on patient and nursing outcomes.

Methods

Inclusion/exclusion criteria This review included randomised and non-randomised con- trolled studies which compared different models of nursing

care involving nurses with varying skill mix. Reports pub- lished from the year 2000 and in the English language only were considered in this review. Studies that involved patients aged 18 years and over and nurses who worked in hospital settings were included. Studies undertaken in community settings and those involved midwifery practices were excluded. The focus of this review was on acute inpatient settings, and midwifery practice and community nursing represent unique contexts, warranting a discipline-specific systematic review. Studies that compared any models of nursing care delivery including team nursing, primary nursing, functional nursing and case management models were included. Studies that had all RN staffing were excluded unless they were compared with a mixed skill model. In the current health environment, having an all RN staffing in the hospital setting is highly unlikely1; therefore, these studies were excluded to reflect the current staffing skill mix. Patient-, nurse- and organisation-related outcomes were evaluated. Patient-related outcomes of interest were the following: (i) incidence of errors and adverse events including complaints, failure to rescue, falls, pressure sores, morbidity and mortality; (ii) length of hospital stay and readmission; (iii) quality of patient care; and (iv) patient satisfaction. The nursing outcomes of interest were the fol- lowing: (i) inter-professional communication, role clarity, professional development and support from senior staff; (ii) job satisfaction; (iii) staff attrition rate; and (iv) nursing documentation. Cost effectiveness was assessed as an organisational outcome. These outcomes were selected as the evidence14,15 demonstrates that nursing skill mix can have an impact on the outcomes listed.

Search strategy With the assistance of a qualified health librarian, the follow- ing databases were searched: Medline (1985–2011), CINAHL (1985–2011), EMBASE (1985 to current) and the Cochrane Controlled Studies Register (Issue 3, 2011 of Cochrane Library). The search terms used were nursing care delivery systems, nursing models of care, personnel staffing and scheduling, nurse–patient ratio and nursing service. A detailed description of the search strategy used can be obtained from the authors. Additionally, the reference lists and bibliographies of all possible studies and reviews were searched for further references. Relevant conference pro- ceedings, key word searching of the World Wide Web and grey literature were looked at using the above-mentioned keywords to complement the search strategies. The follow- ing sites for grey literature were searched: OpenGrey, Vir- ginia Henderson International Nursing Library and the New York Academy of Medicine.

Study selection, assessment of methodological quality and data extraction All abstracts identified from the literature search were screened by two reviewers. There was 100% concordance between the two reviewers. The relevant full text articles/ reports were obtained and assessed for eligibility against the inclusion/exclusion criteria independently by two reviewers.

Models of care in nursing 325

Studies that met the inclusion criteria were selected for potential inclusion. Studies that were reported in more than one publication were included only once. Any disagree- ments were resolved by discussion with a third reviewer. The methodological quality of the eligible studies was assessed independently by two reviewers using the Joanna Briggs quality assessment tool for experimental and non- experimental studies (Table 1). There was 100% concor- dance between the two reviewers. Methodological quality assessment was according to the following criteria: (i) detailed description of inclusion and exclusion criteria used to obtain the sample; (ii) evidence of allocation concealment at randomisation; (iii) the validity of methods of outcome assessment; (iv) description of withdrawals and dropouts; and (v) the potential for bias in outcome assessment. The minimum score obtainable for methodological quality using these tools was 10 and maximum of 30. For this review, the mean quality score minus one SD was adopted as the thresh- old for defining studies of adequate quality.20 Studies that obtained a quality score equal to or above this threshold were included in the analysis, while those that did not meet the threshold quality score were excluded. Data extraction was undertaken by one reviewer using a data extraction tool that was developed for the review. All data extracted were checked by a second reviewer.

Data analysis Data were analysed using the RevMan 5.1 software (Nordic Cochrane Centre, Copenhagen, Denmark). Odds ratios and 95% confidence intervals were calculated for dichotomous outcomes. Analysis of continuous outcomes involved calcu- lation of the mean and SD to derive standardised mean differences and 95% confidence intervals. As the studies were heterogeneous in terms of the various models of care and outcomes assessed, meta-analysis could not be under- taken. Therefore, the results are summarised as a narrative report with forest plots presented where relevant.

Results Approximately 3000 studies were identified from the search strategy. The majority were rejected based on the inclusion and exclusion criteria. Sixteen studies were critically appraised for methodological quality. Based on the criteria for quality assessment, the calculated mean quality score was 22.9 (SD � 3.0; range 20–28); therefore, the quality thresh- old was considered to be 20. Fourteen studies involving a total of 2000 participants were included in the final analysis based on the quality threshold (Fig. 1). The majority of the studies included were comparative studies with concurrent controls. Due to the nature of the interventions, none of the participants or the patients were blinded to the treatment groups.

The majority (n = 5) of the studies included in the review were conducted in the Unites States; the remaining were conducted in Norway, Australia, the UK, Netherlands, Ireland, Sweden, Hong Kong, Italy and Canada. The models of care implemented included team nursing, primary nursing, patient allocation and hybrid models of care delivery (Table 2).

The number of participants in the studies ranged from 2026 to 1137 nurses29 (Table 3). The mean age of the nurses ranged from 35.5 to 60.1 year. In the three studies that reported the gender of the nurses, the majority (87–94%) were female nurses. Studies were carried out in both public and private hospitals. The various models of care reported were implemented in general hospital wards,8,25,26,28–30

medical surgical wards,12,24,27,31 orthopaedic, psychiatric ward,7 intensive care unit22 and acute care23,27 (Table 3).

Effect of the model of care on patient outcomes Errors and adverse events Medication errors. Two studies23,28 investigated the effects of team models of care on medication incidents and adverse intravenous outcomes.23 The number of medication inci- dents at the 6-month follow up was higher than baseline but

Table 1 Critical appraisal checklist

JBI critical appraisal checklist for experimental studies Reviewer _____ Date _____ Author _____ Year _____ Record Number _____

Yes No Unclear 1. Was the assignment to treatment groups truly random? � � � 2. Were participants blinded to treatment allocation? � � � 3. Was allocation to treatment groups concealed from the allocator? � � � 4. Were the outcomes of people who withdrew described and included in the analysis? � � � 5. Were those assessing outcomes blind to the treatment allocation? � � � 6. Were the control and treatment groups comparable at entry? � � � 7. Were groups treated identically other than for the named interventions? � � � 8. Were outcomes measured in the same way for all groups? � � � 9. Were outcomes measured in a reliable way? � � �

10. Was appropriate statistical analysis used? � � � Overall appraisal: Include � Exclude � Seek further info. � Comments (Including reasons for exclusion) ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________

326 R Fernandez et al.

declined to below baseline values at the 12-month follow up in the team model.23 Similarly, the incidence of medication errors was significantly lower at the 18-month follow up when compared with baseline values following the introduc- tion of the team model of care.28

The percentage of adverse intravenous outcomes decreased at 6- and 12-month follow up in the team model.23 There was no statistically significant difference in the incidence of adverse intravenous between the mixed skill team model and all RN model at the 6- (P = 0.35) and 12-month (P = 0.19) follow up23 (Fig. 2).

Falls. Two studies23,28 investigated the incidence of patient falls in team models of care delivery. In the first trial,23 the fall rates per patient day in the mixed skill team model was

significantly higher (P = 0.006) at the 12-month follow up compared with the all RN model (0.002).23 In the second trial28 that investigated the impact of team nursing, there was no significant difference in the rates of falls at 6-, 9- and 12-month follow up (P > 0.05).28

Pain. One trial24 assessed pain scores among patients who received team nursing and patient care delivery models. Pain scores at the 24- to 48-h follow up were significantly lower among general patients in the team nursing model24 com- pared with total patient care (P = 0.005) (Fig. 3).

Other adverse events. Two studies investigated the effect of a hybrid model (combination of patient allocation and team nursing) of nursing care delivery. In the first trial,27 no

Table 2 Description of the various models of care

Author Model of care

Boumans et al.21 Patient oriented care: a form of primary nursing with all RNs. Two RNs were responsible for a specific group of about six patients for 8 h a day (one work shift), 5 days a week

Differentiated practice: a form of team nursing. Involves RNs, ENs and nurse aides. Nurses with varying skill levels Gill et al.22 Team nursing: nurses allocated to groups of patients for variable but usually considerable lengths of time

Non-team nursing: patient allocation model Tourangeau

et al.23 The partnership nursing care delivery model: partnership between two RNs and one personal support assistant on

day and evening shifts to complete all work All RN staffing model

Barkell et al.24 Team nursing model: PCAs assisting RNs. Role of RN was to direct and oversee patient care, delegate basic patient care activities

Total patient care: RN was responsible for giving total care to patient Malkin25 Primary nursing: RN was responsible for giving total care to patient

Non-primary nursing RN and EN responsible for giving total care to patient McPhail et al.26 Primary nursing: RN assumes direct responsibility for the care of a given number of patients and was paired with

associate primary nurse and registered nursing assistants Team nursing: no description

Morris et al.7 Nurse-directed care model: (hybrid) combined components of primary nursing and team nursing models Pre-implementation: custodial model (not stated)

Fowler et al.27 Collaborative ‘shared care’ model: (hybrid) contained elements of patient allocation and team nursing models of care

Pre-implementation model: not stated Seago28 Patient focused care: team approach to care delivery

Primary nursing: no description given Tran et al.8 Shared care in nursing model: team work comprising of RNs, ENs and assistants

Patient allocation: one RN is responsible for total care of a number of patients Sjetne et al.29 Team leader dominated: a team of nurses is responsible for a small group of patients

Primary nurse dominated: a single nurse is responsible for all care to a strictly limited number of patients during their hospital stay

Hybrid (combination of team leader and primary care) Glandon et al.12 Team nursing: team of RNs, LPNs and aides provide care under the supervision of the team leader

Primary nursing: care of a specific patient is under the continuous guidance of one nurse from admission to discharge

Modular model: a group of staff to care for a group of patients Total patient care: nurses are responsible for total care of a patient but only for the hours that specific nurse is

present Kangas et al.30 Team nursing: RNs, LPNs and AINs form a team to provide care for a group of patients. Tasks are divided according

to skill level Case management: nurses assigned specific patients to follow and monitor throughout their hospital stay Primary nursing: RNs cared for a consistent group of patients over a time as acuity and nurse scheduling allowed

MacLeod and Sella31

Primary nursing: care coordinated by primary nurse Pre-implementation model: team nursing

AINs, assistants in nursing; ENs, enrolled nurses; LPN, licensed practical nurse; PCA, patient care assistant; RNs, registered nurses.

Models of care in nursing 327

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-p ri

m ar

y n

u rs

in g

: R N

an d

EN re

sp o n

si b

le fo

r g

iv in

g to

ta l

ca re

to p

at ie

n t

N o

si g

n ifi

ca n

t d

iff er

en ce

b et

w ee

n th

e tw

o m

o d

el s

re la

ti n

g to

• In

tr in

si c

jo b

sa ti

sf ac

ti o n

• Ex

tr in

si c

jo b

sa ti

sf ac

ti o n

• In

te n

ti o n

s to

st ay

in n

u rs

in g

• P er

ce p

ti o n

o f

n u rs

in g

as ‘w

o m

en ’s

w o rk

’

328 R Fernandez et al.

M cP

h ai

l et

a l.2

C an

ad a

R C

2 8

2 0

n u rs

es an

d 1 0 8

p at

ie n

ts fr

o m

a m

ed ic

al /s

u rg

ic al

u n

it in

a te

rt ia

ry ca

re te

ac h

in g

h o sp

it al

Fo llo

w u p

: 8

m o n

th s

P ri

m ar

y n

u rs

in g

: R N

as su

m es

d ir

ec t

re sp

o n

si b

ili ty

fo r

th e

ca re

o f

a g

iv en

n u m

b er

o f

p at

ie n

ts an

d w

as p

ai re

d w

it h

as so

ci at

e p

ri m

ar y

n u rs

e an

d re

g is

te re

d n

u rs

in g

as si

st an

ts Te

am n

u rs

in g

: n

o d

es cr

ip ti

o n

N o

si g

n ifi

ca n

t d

iff er

en ce

b et

w ee

n th

e tw

o m

o d

el s

re la

ti n

g to

• In

te rp

er so

n al

re la

ti o n

sh ip

• P er

so n

al g

ro w

th •

R o le

cl ar

it y

an d

co n

tr o l

• Q

u al

it y

o f

p at

ie n

t ca

re •

P at

ie n

t sa

ti sf

ac ti

o n

M o rr

is et

a l.7

U SA

P re

- an

d p

o st

-s tu

d y

2 3

5 3

n u rs

in g

an d

p ar

ap ro

fe ss

io n

al st

af f

fr o m

a st

at e

p sy

ch ia

tr ic

h o sp

it al

Fo llo

w u p

: 9

m o n

th s

N u rs

e- d

ir ec

te d

ca re

m o d

el :

(h yb

ri d

) co

m b

in ed

co m

p o n

en ts

o f

p ri

m ar

y n

u rs

in g

an d

te am

n u rs

in g

m o d

el s

P re

-i m

p le

m en

ta ti

o n

: cu

st o d

ia l

m o d

el (n

o t

st at

ed )

Fo llo

w in

g im

p le

m en

ta ti

o n

o f

th e

h yb

ri d

m o d

el •

9 0 %

im p

ro ve

m en

t in

cl in

ic al

p ra

ct ic

es an

d cl

ie n

t liv

in g

en vi

ro n

m en

t •

R ed

u ct

io n

in in

ci d

en ts

o f

se cl

u si

o n

an d

re st

ra in

Fo w

le r

et a l.2

A u st

ra lia

P re

- an

d p

o st

-s tu

d y

2 5

Tw o

ac u te

ca re

w ar

d s

at a

te ac

h in

g h

o sp

it al

Fo llo

w u p

: 1

ye ar

C o lla

b o ra

ti ve

‘s h

ar ed

ca re

’ m

o d

el :

(h yb

ri d

) co

n ta

in ed

el em

en ts

o f

p at

ie n

t al

lo ca

ti o n

an d

te am

n u rs

in g

m o d

el s

o f

ca re

P re

-i m

p le

m en

ta ti

o n

m o d

el n

o t

st at

Fo llo

w in

g im

p le

m en

ta ti

o n

o f

th e

h yb

ri d

m o d

el •

5 0 –7

0 %

im p

ro ve

m en

t in

co m

p lia

n ce

to d

o cu

m en

ta ti

o n

• 1 0 0 –4

0 0 %

in cr

ea se

in re

p o rt

ed in

fe ct

io n

in ci

d en

ts •

3 5 –7

1 %

in cr

ea se

in re

p o rt

ed ac

ci d

en ts

/i n

ci d

en ts

• N

o ch

an g

e in

re p

o rt

ed p

re ss

u re

ar ea

s •

3 1 –4

6 %

in cr

ea se

in st

af f

si ck

ra te

Se ag

o 2

U SA

C ro

ss se

ct io

n al

2 0

Te rt

ia ry

ca re

h o sp

it al

in th

e sa

m e

ci ty

w it

h tw

o d

iff er

en t

ca m

p u se

s Fo

llo w

u p

: 6

an d

1 2

m o n

th s

To ta

l sa

m p

le n

o t

st at

ed P o w

er an

al ys

is st

at ed

P at

ie n

t fo

cu se

d ca

re (P

FC ):

te am

ap p

ro ac

h to

ca re

d el

iv er

y P ri

m ar

y n

u rs

in g

: n

o d

es cr

ip ti

o n

g iv

Fo llo

w in

g im

p le

m en

ta ti

on of

th e

PF C

m od

el 6 -m

o n

th fo

llo w

u p

• Si

g n

ifi ca

n t

d ec

re as

e in

m ed

ic at

io n

er ro

rs p

er p

at ie

n t

d ay

• N

o d

iff er

en ce

in th

e in

ci d

en ce

o f

fa lls

• N

o d

iff er

en ce

in th

e p

ro p

o rt

io n

o f

p re

ss u re

u lc

er s

p er

p at

ie n

t d

ay •

Si g

n ifi

ca n

t in

cr ea

se in

jo b

d is

sa ti

sf ac

ti o n

• N

o si

g n

ifi ca

n t

ch an

g es

in th

e o th

er jo

b co

n te

n t

su b

sc al

es ,

o rg

an is

at io

n al

cl im

at e

sc al

es ,

h o sp

it al

cu lt

u re

o r

h ea

lt h

st at

u s

1 2 -m

o n

th fo

llo w

u p

• N

o d

iff er

en ce

in m

ed ic

at io

n er

ro rs

p er

p at

ie n

t d

ay co

m p

ar ed

w it

h 6 -m

o n

th fo

llo w

u p

• N

o d

iff er

en ce

in th

e in

ci d

en ce

o f

fa lls

• Si

g n

ifi ca

n t

d ec

re as

e in

th e

p ro

p o rt

io n

o f

p re

ss u re

u lc

er s

p er

p at

ie n

t d

ay co

m p

ar ed

w it

h 6 -m

o n

th fo

llo w

u p

• Si

g n

ifi ca

n t

in cr

ea se

in jo

b d

is sa

ti sf

ac ti

o n

• N

o si

g n

ifi ca

n t

ch an

g es

in th

e o th

er jo

b co

n te

n t

su b

sc al

es ,

o rg

an is

at io

n al

cl im

at e

sc al

es ,

h o sp

it al

cu lt

u re

o r

h ea

lt h

st at

u s

Tr an

et a l.8

A u st

ra lia

C o m

p ar

at iv

e st

u d

y w

it h

co n

cu rr

en t

co n

tr o ls

2 6

1 5 0

n u rs

es fr

o m

fo u r

m ed

ic al

/s u rg

ic al

w ar

d s

Fo llo

w u p

: 6

m o n

th s

Sh ar

ed ca

re in

n u rs

in g

m o d

el :

te am

w o rk

co m

p ri

si n

g o f

R N

s, EN

s an

d as

si st

an ts

(n =

7 4 )

P at

ie n

t al

lo ca

ti o n

: o n

e R N

is re

sp o n

si b

le fo

r to

ta l

ca re

o f

a n

u m

b er

o f

p at

ie n

ts .

(n =

5 1 )

6 -m

o n

th fo

llo w

u p

N u rs

es in

th e

sh ar

ed ca

re m

o d

el w

ar d

h ad

si g

n ifi

ca n

t d

ec re

as e

in sa

ti sf

ac ti

o n

w it

h co

-w o rk

er s

N o

d iff

er en

ce b

et w

ee n

th e

tw o

m o d

el s

o f

ca re

re la

ti n

g to

o ve

ra ll

jo b

sa ti

sf ac

ti o n

, st

re ss

, jo

b te

n si

o n

an d

ro le

Sj et

n e

et a l.2

N o rw

ay C

o m

p ar

at iv

e st

u d

2 3

1 1 3 7

n u rs

es fr

o m

g en

er al

w ar

d s

in N

o rw

eg ia

n h

o sp

it al

s Fo

llo w

u p

: si

n g

le p

o in

t su

rv ey

Te am

le ad

er d

o m

in at

ed :

a te

am o f

n u rs

es is

re sp

o n

si b

le fo

r a

sm al

l g

ro u p

o f

p at

ie n

ts P ri

m ar

y n

u rs

e d

o m

in at

ed :

a si

n g

le n

u rs

e is

re sp

o n

si b

le fo

r al

l ca

re to

a st

ri ct

ly lim

it ed

n u m

b er

o f

p at

ie n

ts d

u ri

n g

th ei

r h

o sp

it al

st ay

H yb

ri d

(c o m

b in

at io

n o f

te am

le ad

er an

d p

ri m

ar y

ca re

)

Te am

le ad

er w

ar d

• W

as si

g n

ifi ca

n tl

y b

et te

r in

p ro

vi d

in g

a b

et te

r le

ar n

in g

cl im

at e

fo r

n u rs

es •

D em

o n

st ra

te d

h ig

h er

jo b

sa ti

sf ac

ti o n

am o n

g ag

en cy

n u rs

es R el

at io

n sh

ip w

it h

p h

ys ic

ia n

w as

w o rs

e in

w ar

d s

w it

h p

ri m

ar y

th an

w it

h h

yb ri

d m

o d

el N

o d

iff er

en ce

in q

u al

it y

o f

p at

ie n

t ca

re b

et w

ee n

th e

m o d

el s

Models of care in nursing 329

T a b

le 3

C on

ti n u ed

A u th

o r/

co u n

tr y/

st u d

y d

es ig

n Q

u al

it y

sc o re

Sa m

p le

M o d

el o f

ca re

R es

u lt

G la

n d

o n

et a l.1

U SA

Su rv

2 4

3 9 2

m ed

ic al

an d

su rg

ic al

u n

it s

in 6 2

U S

h o sp

it al

s Fo

llo w

u p

: si

n g

le p

o in

t su

rv ey

Te am

n u rs

in g

: te

am o f

R N

s, LP

N s

an d

ai d

es p

ro vi

d e

ca re

u n

d er

th e

su p

er vi

si o n

o f

th e

te am

le ad

er P ri

m ar

y n

u rs

in g

: ca

re o f

a sp

ec ifi

c p

at ie

n t

is u n

d er

th e

co n

ti n

u o u s

g u id

an ce

o f

o n

e n

u rs

e fr

o m

ad m

is si

o n

to d

is ch

ar g

e M

o d

u la

r m

o d

el :

a g

ro u p

o f

st af

f to

ca re

fo r

a g

ro u p

o f

p at

ie n

ts To

ta l

p at

ie n

t ca

re :

n u rs

es ar

e re

sp o n

si b

le fo

r to

ta l

ca re

o f

a p

at ie

n t

b u t

o n

ly fo

r th

e h

o u rs

th at

sp ec

ifi c

n u rs

e is

p re

se n

N u rs

in g

D o lla

rs P er

P at

ie n

t D

ay Te

am 5 8 .7

3 M

o d

u la

r 6 0 .5

5 To

ta l

P at

ie n

t C

ar e

6 3 .8

3 P ri

m ar

y 6 8 .2

2 O

ve ra

ll A

ve ra

g e

(n =

3 9

2 )

6 4 .1

0 R N

D o lla

rs P er

P at

ie n

t D

ay Te

am (n

= 6 0 )

4 1 .2

9 M

o d

u la

r (n

= 6 9 )

4 2 .0

0 To

ta l

P at

ie n

t C

ar e

(n =

1 1 8 )

5 0 .0

0 P ri

m ar

y (n

= 1 4 5 )

5 6 .1

5 O

ve ra

ll A

ve ra

g e

(n =

3 9

2 )

4 9 .5

4 N

u rs

in g

D o lla

rs P er

U n

it o f

W o rk

lo ad

Te am

(n =

6 0 )

$ 4 1 .9

3 M

o d

u la

r (n

= 6 9 )

$ 4 2 .4

9 To

ta l

P at

ie n

t C

ar e

(n =

1 1 8 )

$ 4 2 .5

2 P ri

m ar

y (n

= 1 4 5 )

$ 4 6 .8

3 O

ve ra

ll A

ve ra

g e

P <

0 .0

5 $ 4 4 .0

2 N

u m

b er

o f

B ed

s Te

am $ 3 9 .1

M o d

u la

r $ 3 6 .6

To ta

l P at

ie n

t C

ar e

$ 2 9 .2

P ri

m ar

y $ 2 9 .3

O ve

ra ll

A ve

ra g e

P <

0 .0

5 $ 3 2 .0

K an

g as

et a l.3

U SA

C o m

p ar

at iv

e st

u d

y w

it h

co n

cu rr

en t

co n

tr o ls

2 2

9 2

n u rs

es an

d 9 0

p at

ie n

ts fr

o m

th re

e d

iff er

en t

h o sp

it al

s th

at al

l h

ad d

iff er

en t

ap p

ro ac

h es

to n

u rs

in g

ca re

Fo llo

w u p

: 1 2

m o n

th s

Te am

n u rs

in g

: R N

s, LP

N s

an d

A IN

s fo

rm a

te am

to p

ro vi

d e

ca re

fo r

a g

ro u p

o f

p at

ie n

ts ;

ta sk

s ar

e d

iv id

ed ac

co rd

in g

to sk

ill le

ve l

C as

e m

an ag

em en

t: n

u rs

es as

si g

n ed

sp ec

ifi c

p at

ie n

ts to

fo llo

w an

d m

o n

it o r

th ro

u g

h o u t

th ei

r h

o sp

it al

st ay

. P ri

m ar

y n

u rs

in g

: R N

s ca

re d

fo r

a co

n si

st en

t g

ro u p

o f

p at

ie n

ts o ve

r a

ti m

e as

ac u it

y an

d n

u rs

e sc

h ed

u lin

g al

lo w

A cr

o ss

th e

th re

e m

o d

el s

th er

e w

as •

N o

d iff

er en

ce in

n u rs

es jo

b sa

ti sf

ac ti

o n

sc o re

s •

N o

d iff

er en

ce in

p at

ie n

t sa

ti sf

ac ti

o n

w it

h n

u rs

in g

ca re

M ac

Le o d

an d

Se lla

3 1

U SA

P re

- an

d p

o st

-s tu

d y

2 2

3 7

n u rs

es in

tw o

su rg

ic al

an d

tw o

m ed

ic al

u n

it s

in a

te rt

ia ry

te ac

h in

g h

o sp

it al

Fo llo

w u p

: 1 2

m o n

th s

P ri

m ar

y n

u rs

in g

: ca

re co

o rd

in at

ed b

y p

ri m

ar y

n u rs

e P re

-i m

p le

m en

ta ti

o n

m o d

el w

as te

am n

u rs

in g

P ri

m ar

y n

u rs

in g

• In

cr ea

se d

q u al

it y

o f

ca re

re p

o rt

ed b

y R N

s •

D ec

re as

ed q

u al

it y

o f

ca re

re p

o rt

ed b

y as

so ci

at e

n u rs

es •

H ig

h er

ab ili

ty to

id en

ti fy

an d

m ee

t p

at ie

n t’

s n

ee d

s b

y re

g is

te re

d an

d as

so ci

at e

n u rs

es •

H ig

h er

re sp

o n

si b

ili ty

fo r

p at

ie n

t o u tc

o m

A IN

s, as

si st

an ts

in n

u rs

in g

; EN

s, en

ro lle

d n

u rs

es ;

LP N

, lic

en se

d p

ra ct

ic al

n u rs

e; P C

A ,

p at

ie n

t ca

re as

si st

an t;

R C

T, ra

n d

o m

is ed

co n

tr o l

tr ia

l; R N

s, re

g is

te re

d n

u rs

es .

330 R Fernandez et al.

difference in pressure areas or infection rates was reported following the implementation of the hybrid model of care. In contrast, in the second trial, significant reductions in rates of seclusion and restraint episodes were reported in wards that implemented a hybrid model of nursing care (P < 0.001).7

Length of hospital stay Length of hospital stay was investigated in one trial.24 No significant difference in length of hospital stay was reported

between team nursing and total patient care models for general hospital patients (P = 0.63)24 (Fig. 4).

Quality of patient care Quality of patient care was compared among differentiated care (a form of team nursing),21 primary nursing,31 hybrid (combination of primary nursing and team nursing)7 and partnership models of care.23

Significantly higher levels of compliance among nurses were reported relating to patient assignment, taking nursing

Figure 1 Selection of studies for the review (RNs, registered nurses).

Potentially relevant studies identified and screened for retrieval (n=3000)

Excluded (n=2981) Reason for exclusion Studies did not meet the inclusion criteria based on title and abstract

Eligibility assessment on full-text papers (n=19)

Quality assessment (n=16)

Studies included in final review (n=14)

Studies excluded (n=3) Reason for exclusion Did not meet the inclusion criteria

Studies excluded (n=2) Reason for exclusion Model included only all RNs

Figure 2 Percentage of adverse intravenous outcomes at 6- and 12-month follow up (RNs, registered nurses).

Models of care in nursing 331

history, assessing nursing problems, setting patient goals and instituting relevant nursing interventions to achieve these goals in differentiated care (team) model compared with the functional (task) model of care (P = 0.00).21 In another small study (n = 10), nurses in the primary nursing model perceived that they were able to provide better quality of care.31 In this study, quality of care related to nurses’ role strain was associated with the new model of care.31 Significant improvement in staff knowledge of their patients and relevant clinical information was reported post- implementation of a hybrid model of nursing care.7 Similarly, significant improvement in all aspects of care including number of showers (pre, 37.5%; post, 77.4%), adequate clothing (pre, 22%; post, 80%) and neat living environment (pre, 38%; post, 94%) was found post-implementation of the hybrid model of care.7 Educating patients relating to intravenous therapy increased significantly in 6 (50%) and 12 months (79%) following the introduction of the partner- ship model.23 The partnership model23 however was associ- ated with RNs spending less time in assisting patients with activities of daily living. In another study,26 the quality of care provided by nurses was undertaken by surveying health professionals. The results indicated that high-quality care was provided by nurses in both the team and primary nursing models.

Patient satisfaction Four studies24,26,28,30 investigated patient satisfaction bet- ween the various models of care; however, data were presented in only two studies. In these two studies, no statistically significant difference in patient satisfaction

between team nursing and primary nursing models26 and total patient care models24 was found (P > 0.05) (Fig. 5). In the remaining two studies, patients were satisfied with their nursing care overall irrespective of whether the model of care was team nursing, case management or primary nurs- ing.30 Similarly, patient satisfaction remained the same across the three time periods following the change from total patient care to team-based care.28

Effect of model of care on nursing outcomes Communication Inter-professional communication. Inter-professional com- munication was investigated in two studies.21,29 The relation- ship with physician was reported to be worse in wards with primary nursing compared with hybrid29 models of care. In the second trial,21 no significant differences in communica- tion factors were reported between differentiated (team) care and functional (task) nursing models of care (P > 0.05).

Role clarity. In a randomised crossover trial undertaken on 21 nurses,26 less clarity in the primary nursing care delivery system compared with team nursing was reported. However, this result was not statistically significant. In this study, clarity was related to how explicitly policies and pro- cedures were communicated and the extent to which nurses know what to expect in their daily routines.26 There was also no statistically significant difference in total scores relat- ing to work environment in the two models of nursing care delivery.26

Documentation. Four studies22,24,26,27 investigated the effect of team nursing on compliance with documentation in the

Figure 3 Pain scores at the 24- to 48-h follow up.

Figure 4 Length of hospital stay.

332 R Fernandez et al.

medical records. Overall compliance with documentation was reported to be higher in the team nursing model of care. In one study,26 a medical record audit of 20 patient charts demonstrated a compliance rate of 80.2% in the primary care model and 92% in the team nursing model. Similarly, significant improvement in compliance to documentation (up to 70%) and reporting of incidents was observed in a shared care model (team).27 In the third study, documenta- tion practice scores relating to pain were significantly higher in the team nursing model (7.5 SD 2.67) compared with the total patient care model (6.0 SD 2.79) (P = 0.006).24 In contrast, in the final study, monthly care audits demonstrated no significant difference in patient care between the team nursing and patient allocation models of care.22

Discharge planning. RN participation in discharge plan- ning increased significantly in 6 months following the imple- mentation of a partnership model.23

Professional development One trial29 assessed three models of care on staff profes- sional development. The team nursing model of care was significantly better in providing a learning climate for RNs compared with primary nurse dominated, hybrid models.29

Support from senior staff Two studies21,31 investigated nurses’ perceptions of support received from senior staff in the different models of care. In one study,21 nurses in the differentiated care model experi- enced significantly less social and emotional support from their supervisor compared with those implementing the functional nursing model of care delivery. In the second study,31 nurses perceived that they had more support from the head nurse under the primary nursing model.

Nurse absenteeism rates Two studies investigated nurse absenteeism rates among various models of care. No significant differences were

reported in the number of times and the duration of absen- teeism among nurses in the functional nursing,26 team nurs- ing26 and primary nursing models of care.26 However, significantly more health complaints among nurses in the differentiated practice model were reported compared with the primary nursing model (P = 0.03).21

Job satisfaction Team nursing compared with other models. Six studies8,22,23,28–30 investigated job satisfaction among nurses implementing the team nursing model of care. Higher job satisfaction was reported only among agency nurses29 in team leader wards (team) compared with wards that imple- mented primary or hybrid nursing model of care. In the second trial,30 job satisfaction among nurses was non- significantly higher in wards with team nursing compared with wards that had the case management and primary nursing models (Fig. 6).

In the third trial,23 there was a marginal reduction in job dissatisfaction levels from baseline values (mean score 23.61) at the 6- (21.87) and 12- (22.37) month follow-up period following the implementation of the team partnership model of care. In the fourth study,8 there was no significant difference relating to job satisfaction, role clarity, stress in general and tension index between nurses who imple- mented the shared care model a form of team nursing and the patient allocation model. There was a significant decrease in satisfaction with co-workers in the shared care model of care.8 In contrast, job dissatisfaction increased significantly between the 12- and 24-month follow up (P < 0.0001) following the introduction of the team nursing model of care.28 Similar results were reported at the 3-month follow up where 53% of the nurses stated that they were satisfied with the team nursing model of care compared with 69% for the patient allocation method. A significant differ- ence was observed at the 6-month follow up where 69% of the nurses in the patient allocation model of care compared with 1% in the team nursing model stated that they were satisfied with the style of nursing22 (Fig. 7).

Figure 5 Patient satisfaction.

Models of care in nursing 333

Primary nursing compared with other models. One trial25

investigated job satisfaction among nurses using primary nursing model of care. In this study,25 no significant differ- ence was demonstrated between primary and non-primary nurses’ levels of intrinsic job satisfaction or intentions to stay in nursing. Similarly, no significant difference was demon- strated between primary and non-primary nurses’ levels of extrinsic job satisfaction or perceptions of nursing as a woman’s work.25

Effect of the model of care on organisational outcomes Cost effectiveness Three studies12,23,24 reported the cost effectiveness of the various models of nursing care. In the first study,12 cost effectiveness in terms of nursing dollars per patient day and nursing dollars per unit of workload was calculated for team nursing, modular nursing, total patient care and primary nursing care models. The results indicated that the team model of care was the least expensive (US$58.73) when compared with modular nursing (US$60.55), total patient care (US$63.83) and primary nursing (US$68.22) care model. Similarly, the nursing dollars per unit of workload was the least expensive in the team model of care.12 In the second study24 that compared team nursing model with

total patient care in North America, no significant difference (P = 0.721) in variable costs (including staff salaries and patient care costs) was reported following the implementa- tion of total patient care. The third study23 investigated the average cost of nursing care between an all RN nursing staff model (primary) and a mixed skill partnership model (team). The cost required per patient hour for the mixed skill part- nership model increased from $28 at baseline to $33 Cana- dian at the 12-month follow up. On the other hand, the cost required per patient hour for the all RN model increased from $30 to $37 Canadian at the 12-month follow up. These differences were not statistically significant.

Discussion

This systematic review was undertaken to assess the efficacy of the various models of nursing care delivery on patient, nursing and organisational outcomes. The initial search iden- tified an array of designs and methods; however, this review has only focused on quantitative studies that included various levels of nurses. Following assessment of method- ological quality, only 14 studies were eligible for inclusion in this review. Except for the study design, all studies scored highly on the quality scale. This is understandable given the

Figure 6 Job satisfaction among nurses.

Figure 7 Satisfaction with the style of nursing.

334 R Fernandez et al.

difficulties inherent in randomisation, allocation and blind- ing associated with such interventions.

Although the quality scores were modest, aspects of good design including sample size estimation and disclosure of follow-up data need to be considered within future studies. The outcome measures were diverse limiting the meta- analysis of data. In addition, the instruments used to measure outcomes and audit patient records could have not been sensitive enough to detect changes. This considerable heterogeneity reflects the context within which this review was undertaken.

Patient outcomes The results of this review relating to the effect of a team nursing model on the incidence of falls remain inconclusive as one study28 demonstrated significant decrease in the number of falls at the 2-year follow up and no difference in the 6-, 9- and 12-month follow up. In contrast, in the second study,23 there was a higher incidence of falls in the team nursing ward compared with the patient allocation ward. This result could be due to the fact that the patient allocation ward had all RNs and those in the team nursing ward had nurses with varying skill levels.

In contrast to falls, wards that implemented the team nursing model of care demonstrated significantly lower pain scores24 and incidence of medication errors and adverse intravenous outcomes at the 12- and 18-month follow up.23,28 This reduction in the errors and adverse events could be attributed to the increased time available for RNs to educate patients about medications and intravenous therapy.

Wards that used a hybrid model that was a combination of patient allocation and team nursing models demonstrated significant improvement in quality of patient care, reduction in restraint use and rates of seclusion,7 but no difference in incidence of pressure areas or infection rates.27 No significant differences were found in model comparisons relating to length of stay24 and aspects of patient satisfaction.24,26,28,30

Although indirectly related to patient outcomes, several studies examined the quality of nursing documentation with team nursing being superior to that of primary nursing model,26 although one study22 found no difference. Early discharge was also supported by a team nursing model.

Nursing outcomes Several studies investigated the effect of various models of care on inter-professional communication. The results dem- onstrate better communication with physicians in wards that implemented hybrid29 model of care. Role clarity was dimin- ished in primary nursing models compared with team nursing although not statistically significant.26 Similarly, a team nursing variant (shared care) also found no difference in role clarity/confusion compared with patient allocation.8

As issues of role clarity and confusion were not different across several comparison studies of varying models, there may be the need for clarification of roles of the varying staff members within any model. This could therefore be an issue related to role description rather than the model.

In one study,29 the team nursing model of care provided a better learning environment for nurses. Inexperienced and newly graduated RNs and other levels of nurses need to be supported in the early years of their transition into practice or in their orientation to new areas, and models that support this transition have intuitive advantage.32 Where unit staffing is diverse, and inclusive of ENs or assistants in nursing, then potentially the team nursing model would be more appro- priate based on this single consideration. Few studies exam- ined the model’s ability to support inexperienced nursing staff and should be considered in future studies.

Team nursing and variants of team nursing were often compared with case management primary nursing30 and patient allocation,8 with no significant difference in job sat- isfaction found. Nurse absenteeism, often considered an indicator of satisfaction,33 did not differ across models.21,26

Two studies examined cost effectiveness with the results supporting team nursing versus other models as being the most cost-effective model in one study,12 while the other study found no financial advantage between the models.24

Limitations Despite the evidence, some limitations of this systematic review were noteworthy. Publication bias, a common limi- tation of systematic reviews, may have impacted on this review, particularly in relation to the use of English only studies. Another important aspect throughout the analysis was the small sample sizes. Four studies22,25,26,31 had less than 50 nurses and four studies had between 51 and 100 nurses in the study. Three studies had more than 100 partici- pants8,21,29 and one had 1137 nurses to evaluate three models of care.29 The small sample size in most of the studies could indicate a lack of statistical power to detect differences between the models. There was little evidence that sample size estimation was undertaken, which is a key measure of quality of a study design.34 In future studies, nurse research- ers need to consider sample size estimation, which will ensure adequate testing of hypotheses posed. We acknowl- edge the difficulties inherent in recruiting adequate numbers of nurses into trials and also the problem of loss to follow up in units with high staff turnover.8

Another issue with the studies included was that the defi- nition of the models was often confusing and difficult to distinguish. For example, patient-oriented care described an assigned nurse for the total care of the patients similar to primary nursing21 presumably for only one shift, which is very similar to Tran et al.8 which is referred to as patient allocation (nurse cares holistically for the all the needs of a patient). By far, primary nursing was easily distinguished by the element of continuity of care through a hospital stay, which is not evident in patient allocation. To further compound the problem, some models were a combination of models such as patient allocation, team nursing and primary nursing.7,27 The difficulties of being able to discretely distinguish models and therefore to compare outcomes were evident throughout the review and are the focus of additional work.

Future researchers should precisely define their models with key elements such as patient care for a shift and continuity of

Models of care in nursing 335

care. There is a need for clarification of roles of the varying staff members within teams, groups of patients or tasks (responsi- bility for which tasks) irrespective of the model defined. No weighting has been allocated for varying aspects of consider- ation in patient and nursing outcomes, and this may be relevant to certain settings. For example, a nursing unit may consider that the management of inexperienced staff is the most critical feature and team nursing would be more relevant.

The designs of the studies varied considerably, making comparison of outcomes difficult. Although there was one randomised controlled studies in this review,26 the difficulties of randomisation continue to jeopardise the findings of these studies. Indeed, issues of contamination of the models may be important and may require that studies of models of care use cluster randomised designs, which address the influ- ence of local policies within study units.35

Conclusion

A systematic review of several models of care has been undertaken with a predominance of team nursing within the comparisons, suggestive of its popularity or longevity. Nurse satisfaction, absenteeism and role clarity/confusion pre- dominantly did not differ across model comparisons although the need for clear definition of the role or tasks and accountability of specific nurses remains necessary. Similarly, communication remains a key aspect of good patient care and nursing care delivery and should be fundamental to any implementation of a new model of care. Surprisingly, little benefit was found within primary nursing comparisons and the cost effectiveness of team nursing over other models remains debatable. Nonetheless, team nursing does present a better model for inexperienced staff to develop, a key aspect in units where skill mix or experience is diverse. Contexts such as day surgery may have relevance in the choice of model and should be considered.

This review has provided the best available evidence relat- ing to various models of nursing care on nurse sensitive indicators such as fall incidents, medication errors and infec- tion, with several studies showing no significant difference. These outcome measures are important indicators of care and further studies should include these data.

Acknowledgements

The authors would like to thank the staff at the Sydney South West Area Health Service for supporting this project and providing resources for data extraction.

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