Application: Systems Theory

D I S C U S S I O N P A P E R

Nursing Services Delivery Theory: an open system approach

Raquel M. Meyer & Linda L. O’Brien-Pallas

Accepted for publication 30 July 2010

Re-use of this article is permitted in

accordance with the Terms and Conditions

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Correspondence to R.M. Meyer:

e-mail: [email protected]

Raquel M. Meyer PhD RN

Nursing Early Career Researcher

Ontario Ministry of Health & Long-Term

Care, and

Assistant Professor (CLTA)

Lawrence Bloomberg Faculty of Nursing,

University of Toronto, Ontario, Canada

Linda L. O’Brien-Pallas PhD RN FCAHS

Professor & CHSRF/CIHR Chair in

Nursing Human Resources

Lawrence Bloomberg Faculty of Nursing,

University of Toronto, Ontario, Canada

M E Y E R R . M . & O ’ B R I E N - P A L L A S L . L . ( 2 0 1 0 )M E Y E R R . M . & O ’ B R I E N - P A L L A S L . L . ( 2 0 1 0 ) Nursing services delivery theory:

an open system approach. Journal of Advanced Nursing 66(12), 2828–2838.

doi: 10.1111/j.1365-2648.2010.05449.x

Abstract Aim. This paper is a discussion of the derivation of the Nursing Services Delivery

Theory from the application of open system theory to large-scale organizations.

Background. The underlying mechanisms by which staffing indicators influence

outcomes remain under-theorized and unmeasured, resulting in a ‘black box’ that

masks the nature and organization of nursing work. Theory linking nursing work,

staffing, work environments, and outcomes in different settings is urgently needed to

inform management decisions about the allocation of nurse staffing resources in

organizations.

Data sources. A search of CINAHL and Business Source Premier for the years

1980–2008 was conducted using the following terms: theory, models, organization,

organizational structure, management, administration, nursing units, and nursing.

Seminal works were included.

Discussion. The healthcare organization is conceptualized as an open system

characterized by energy transformation, a dynamic steady state, negative entropy,

event cycles, negative feedback, differentiation, integration and coordination, and

equifinality. The Nursing Services Delivery Theory proposes that input, throughput,

and output factors interact dynamically to influence the global work demands

placed on nursing work groups at the point of care in production subsystems.

Implications for nursing. The Nursing Services Delivery Theory can be applied to

varied settings, cultures, and countries and supports the study of multi-level phe-

nomena and cross-level effects.

Conclusion. The Nursing Services Delivery Theory gives a relational structure for

reconciling disparate streams of research related to nursing work, staffing, and work

environments. The theory can guide future research and the management of nursing

services in large-scale healthcare organizations.

Key words: nursing management, Nursing Services Delivery Theory, open system

approach, organization structure, quality of care, staffing, work organization

Introduction

In many countries, the sustainability and quality of nursing

services are threatened by global shortages of healthcare

professionals (International Council of Nurses 2006). As one

component of a multifaceted response to this crisis, policy

and decision-makers have prioritized the nursing practice

environment and organizational performance as key areas for

2828 � 2010 Blackwell Publishing Ltd

J A N JOURNAL OF ADVANCED NURSING

intervention (International Council of Nurses 2006). Nursing

services are generally contracted through an employment

relationship. To recruit, retain, and deploy scarce nursing

human resources effectively and to produce quality and cost-

effective care, the associations between organizational struc-

tures, human resource management policies and the goals,

resources, context, and outcomes of nurses’ work need to be

understood. A challenge in nursing health services research

has been the need for a unifying theory to conceptualize and

examine the delivery of nursing services (Edwardson 2007).

In the conceptual model for nursing and health policy,

Russell and Fawcett (2005) identified four levels of focus:

(i) nursing practice processes; (ii) administrative practices

for nursing service (or healthcare) delivery subsystems;

(iii) healthcare system administrative practices; and (iv)

world health administrative practices. The Nursing Services

Delivery Theory (NSDT) addresses the second level of

phenomena in this model by examining the effectiveness

and efficiency of administrative practices for nursing service

delivery subsystems. Using the strategy of theory derivation,

the NSDT gives a theoretical understanding of the nature of

an organization, situates the work of nurses in the organi-

zational context, and integrates the design and organization

of nursing work. In this study, we present a description of the

derivation of the NSDT from the application of Open System

Theory to large-scale organizations and the structural and

conceptual elements of the NSDT. Examples from the

empirical literature are used to illustrate the relational

structure the NSDT describes among nursing work, work

environment, and staffing variables. Further implications of

the theory are discussed.

Background

Nursing health services research is characterized by a

growing need for a coherent theoretical framework that

combines clinical, organizational, financial, and outcome

variables from a nursing perspective (Edwardson 2007).

Nurse staffing studies often apply traditional nurse staffing

indicators to give crude estimates of the amount of nursing

resources available for care. However, by virtue of their

simplicity, nurse staffing indicators also de-contextualize

care. Conceptually, hours per patient day (HPPD) assume a

standard time per occupied bed, whereas nurse–patient ratios

are based on average nurse capacity (O’Brien-Pallas et al.

2005). Workload measurement systems quantify patients’

requirements for nursing care as the sum of the times of the

tasks required or as the amount of time required relative to

standard patients (Thibault et al. 1990). In the community,

numbers of visits reflect standard times allotted per home

visit. These types of nurse staffing indicators inadequately

consider factors known to influence variability in nursing

work, namely the characteristics of care recipients and

nursing teams, and factors related to the care delivery

environment (O’Brien-Pallas et al. 1997).

Although staffing research examining large administrative

data sets in the United States of America (USA), Canada, and

the United Kingdom has identified associations between key

nurse staffing indicators and patient outcomes at the

organizational level (Lankshear et al. 2005), these types of

secondary analyses do not measure the actual work

performed by nurses (Clarke 2006). Thus, the underlying

mechanisms by which staffing indicators influence outcomes

remain under-theorized and unmeasured, resulting in a

‘black box’ that masks the nature and organization of

nursing work. Although large database studies allow for

comparisons across organizations, evidence on which to re-

organize and improve nursing services to varied clinical

populations at the point of care is lacking (Clarke 2006).

Specific theory and evidence linking staffing practices and

outcomes in different settings are urgently needed to inform

management decisions about the allocation of nurse staffing

resources in organizations.

A review of funded nursing health services research in the

USA identified that conceptual frameworks were often used

in isolation by researchers (Edwardson 2007). Donabedian’s

(1980) Healthcare Organization and Delivery Model is one

of the most frequently used frameworks to examine nursing

performance (Hall 2004, Edwardson 2007). Conceptual

frameworks of nursing care based on Donabedian’s (1980)

formulation for the assessment of care quality typically

organize patient, nurse, work, work environment, and

outcome variables according to structure, process, and

outcome (e.g. Irvine et al. 1998, Cho 2001). However,

because Donabedian (1980) was focused on an approach

for assessing the quality of medical care, rather than on

system design and organization, the fundamental questions of

‘What is an organization?’ and ‘What is nursing work?’

remain unanswered. Rationales for including variables in a

structure–process–outcome framework have tended to rely

on empirical findings, rather than a theoretical understanding

of the nature of an organization or the delivery of nursing

services. In addition, because linear relationships are fre-

quently assumed between structure, process, and outcome

variables, the dynamic interactions between variables are

often neglected (Mitchell et al. 1998).

Building on a rich tradition of systems thinking in clinical

(Holden 2005) and nursing management, the NSDT

addresses many of these challenges to nurse staffing and

nursing work research. In particular, Jelinek (1967) described

JAN: DISCUSSION PAPER Nursing Services Delivery Theory

� 2010 Blackwell Publishing Ltd 2829

a Patient Care System Model composed of personnel types

and physical facilities as inputs; organizational and environ-

mental factors as throughput; and patient care, patient

satisfaction, and personnel satisfaction as outputs. Subse-

quently, the interrelationships among nursing complexity,

medical complexity, nurse characteristics, environmental

complexity, and outcomes were tested in a systems model

in community and hospital settings to investigate the factors

that cause patients or clients with very similar medical

conditions to have different nurse resource requirements

(O’Brien-Pallas et al. 1997, 2001, 2002, 2004, Meyer et al.

2009). In these models, inputs consisted of the characteristics

of patients or clients, nurses, and the system and system

behaviours; throughput involved the nursing care delivery

subsystem, where nursing interventions are performed and its

environmental complexity; and outputs involved outcomes

for patients or clients, nurses, and the system. Mark et al.

(1996) also applied structural contingency theory, a subset of

Open System Theory, to the evaluation of nursing system

outcomes. Key variables included environment (e.g. organi-

zational size, skill mix), technology (e.g. stability of patient

acuity, diversity of patient conditions), structure (e.g. degree

of centralization), and effectiveness (e.g. patient and admin-

istrative outcomes). The basic premise was that to perform

effectively and to produce quality outcomes, an organization

must structure its nursing units to complement the environ-

ment and technology.

The NSDT complements and extends the scope of

previous systems models in nursing by theorizing the nature

of an organization, locating the work of nursing at the work

group level in an organizational suprasystem, and explicat-

ing the division and coordination of nursing work. By

viewing the healthcare organization through the lens of

objectivism, the work of nurses is assumed to exist as an

objective, external reality with identifiable and measurable

characteristics.

The theory derivation was guided by these questions:

What is the nature of an organization? How do healthcare

organizations produce nursing services? How do manage-

ment structures contribute to the delivery of nursing

services? According to Walker and Avant (2005), theory

derivation is an iterative and creative process that involves:

(i) becoming very familiar with the level of theory develop-

ment in the field and evaluating existing theories; (ii) reading

widely both in and outside the field of study to make creative

associations between distinct fields of study; (iii) choosing a

parent theory for the derivation; (iv) identifying which

content and structural elements of the parent theory will be

used; and (v) recasting these elements for the phenomenon of

interest.

Data sources

Building on our pre-existing knowledge, literature from the

nursing, healthcare, and management fields was examined. A

search of CINAHL and Business Source Premier was

conducted using combinations of the following terms: theory,

models, organization, organizational structure, management,

administration, nursing units, and nursing. The search was

limited to English language, peer-reviewed publications or

books published between 1980 and 2008. Seminal works

were also included. Documents with a major focus on theory

related to work performance and management in organiza-

tions were reviewed.

Discussion

Katz and Kahn’s (1978) The Social Psychology of Organi-

zations, based on Open System Theory, was selected as the

parent theory because it addressed the questions guiding the

derivation in a comprehensive manner and facilitated new

insights and connections about research in the areas of

nursing work, staffing, and work environments. Selected

structural and conceptual elements of the parent theory were

redefined. Specifically, the open system characteristics of

organizations and the five functional subsystem types, which

are the fundamental defining characteristic of social systems

(Katz & Kahn 1978), were recast in the NSDT with an

emphasis on the dynamics and mechanisms of production

subsystems.

Open System Theory

The theoretical foundation of the NSDT is Open System

Theory as applied to large-scale organizations by Katz and

Kahn (1978). In their view, an organization constitutes an

energic input–output system. An organization depends on its

supporting environment for continued inputs to ensure its

sustainability and processes these inputs through the recur-

ring and patterned activities and interactions of individuals to

yield outputs. An organization is therefore essentially a social

system. As such, an organization and its subsystems strive to

achieve a dynamic steady state whereby regularities in energy

flow preserve the character of the system and disturbances

prompt system adaptation (Katz & Kahn 1978). To survive,

an organization needs to counteract entropy, which is an

inevitable process of disorder and dissolution caused by loss

of inputs or by inability to transform energies. An open

system must acquire negentropy (i.e. negative entropy),

usually through some form of storage capacity, to ensure its

continued existence (Katz & Kahn 1978). For organizations,

R.M. Meyer and L.L. O’Brien-Pallas

2830 � 2010 Blackwell Publishing Ltd

negentropy can involve renewing inputs, storing energy,

creating slack resources, or maximizing imported energy

relative to exported energy (Galbraith 1974, Katz & Kahn

1978). Organizations can also counteract entropy by adapt-

ing system functioning in response to informational signals

and feedback from the environment. Characteristics of open

systems and their application to large-scale organizations and

to the NSDT are presented in Table 1.

Open System Theory recognizes the hierarchical nature of

entities, whereby each level of the organization comprises a

‘subsystem’ of interrelated parts. In large-scale organizations,

the transformation of energy (i.e. throughput) occurs in

production subsystems that divide the labour to accomplish

tasks (Katz & Kahn 1978). The function of the production

subsystem is to transform energy to meet task requirements

and to optimize task accomplishment via technical profi-

ciency (Katz & Kahn 1978). The underpinning mechanism is

the division of labour that determines the structure and work

flow in the production subsystem. Subdividing the work

creates breaks in work flow. Organizations address this

challenge by integrating work processes across roles and

subunits using coordination devices (Katz & Kahn 1978). As

an organization differentiates, additional integration and

coordination are required to unify system functioning (Katz

& Kahn 1978). Thus, the size, complexity, and coordination

demands of an organization increase as its subsystems

multiply and specialize in function.

The production subsystems interact dynamically with the

supportive, maintenance, and adaptive subsystems of the

broader organization (Figure 1). These subsystems import

people, materials, and energies through transactions at the

organizational boundaries; balance internal work structures

relative to human inputs by formalizing activities and

socializing and rewarding members; and deal with problems

of adjustment to external forces by recommending and

incorporating change (Katz & Kahn 1978). Overall organi-

zational functioning and adjustment to external demands are

coordinated and integrated by the management subsystem,

which crosscuts and directs all subsystems and negotiates

conflict across hierarchical levels (Katz & Kahn 1978). In

terms of functioning, the production, supportive, mainte-

nance, adaptive, and management subsystems do not operate

in isolation, but rather are interdependent and interact

dynamically as part of a greater, complex whole.

As an open system, the organization adapts its functioning

in response to negative feedback and external informational

signals through a series of iterative adjustments that allow the

system to evolve while maintaining its character (Katz &

Table 1 Open system concepts and their corollary in the Nursing Services Delivery Theory

Concept Definition (Katz & Kahn 1978)

Application to large-scale

organization (Katz & Kahn

1978)

Application to the Nursing

Services Delivery Theory

Inputs The inflow of energy and

information from the external

environment renews the

system

Energic inputs may include

people, materials, or resources

from other organizations.

Informational inputs include

negative feedback or signals

about the external

environment

People – e.g. staff, care

recipients

Materials – e.g. supplies

Resources – e.g. funding

Information – e.g. labour

market conditions

Throughput Energies inside the system are

transformed by reorganizing

the inputs

Reorganization may entail

processing of materials,

generation of products, or

provision of services

Services – e.g. nursing

interventions

Output Product must be exported to

the external environment

Outputs may consist of

materials, products, or

services

Service outputs – e.g. patient

volumes

Systems as cycles

of events

The process of exchanging and

transforming energy must

renew the system thus

creating a repeated series of

activities

Renewal may be generated by

system output or by its own

activities

Outputs – e. g., revenues

Activities – e.g. accreditation

criteria achieved

Negative feedback Internal information about

system functioning is a

corrective device used to

adjust energy intake and

expenditure

Subsystem feedback about

operational functioning is

used to keep the organization

on target

Negative feedback – e.g.

organizational performance

indicators

JAN: DISCUSSION PAPER Nursing Services Delivery Theory

� 2010 Blackwell Publishing Ltd 2831

Kahn 1978). Although Figure 1 is a simplified representation

of the organization as an open system, the phenomenon is

neither uni-dimensional nor static. Large-scale organizations

typically consist of multiple interacting subsystems (e.g.

multiple production subsystems by specialty, hierarchically

layered management subsystems). The principle of equifinality

states that an open system can achieve its end state from

various initial conditions and through differing trajectories

(Katz & Kahn 1978). This suggests that there is no single way

for an organization to be structured or to achieve positive

outcomes.

Nursing Services Delivery Theory

The NSDT applies Open System Theory to nursing work in

large-scale healthcare organizations (Figure 2). With respect

to system structure, the NSDT identifies that care is delivered

by nurses clustered in work groups that are nested in a

department or programme in the larger organization. Inpa-

tient units in a hospital or nursing teams in home healthcare

are examples of production subsystems. These work groups

transform energic inputs to deliver nursing services and to

yield outputs. Imported inputs consist of care recipients, staff,

material and fiscal resources and information, which are

subsequently transformed in a nursing production subsystem

through the work performed, its structure, and its internal

work conditions.

Distal outputs include clinical, human resource, and

organizational outcomes. These energic outputs give feed-

back and reactivate the system in a cyclical manner because

positive outcomes in each of these domains ensure that

members of the community continue to use the organization’s

services, staff are retained to give the services, and the

organization’s accreditation and funding are sustained. With

respect to nurse staffing, entropy may be counteracted in

several ways. Examples of negentropy include: (i) renewal of

inputs by retaining or hiring nurses; (ii) storing energy by

using buffer inventories of nursing capacity (e.g. float pools,

agency nursing); (iii) creation of slack resources by loosening

performance targets to reduce the number of exceptions

(e.g. longer lengths of stay), by increasing fiscal resources

(e.g. greater nursing HPPD), or by extending lead times (e.g.

richer staffing ratios); and (iv) more efficient use of imported

energy relative to exported energy by intensifying nursing

workload to increase volumes (e.g. lower staffing ratios).

In Open System Theory, each system and its subsystems

adapt to internal and external demands and feedback.

Demands external to the healthcare organization encompass

environmental factors (e.g. labour market, legislation, popu-

lation characteristics). Healthcare organizations continuously

Throughput

Organization suprasystem

Management subsystem • Integration & coordination of

system functioning

Supportive subsystem • Importation of inputs

Production subsystem • Transformation of energy

Maintenance subsystem • Formalization of activities & socialization

of members

Adaptive subsystem • Monitoring & responses to external forces

• Change integration

Inputs Outputs

Products

Services

Materials

People

Energies

Figure 1 Simplified representation of the organization as an open system based on Katz & Kahn (Meyer 2010, reproduced with permission).

R.M. Meyer and L.L. O’Brien-Pallas

2832 � 2010 Blackwell Publishing Ltd

adapt system functioning in response to feedback and infor-

mational signals to counteract entropy. For example, aligning

organizational policies to meet performance targets set by

external agencies exemplifies the dynamic interaction between

the organization and its external environment.

At the point of care, each nursing production subsystem

also adapts to and interacts reciprocally with the other

organizational subsystems. The management, supportive,

maintenance, and adaptive subsystems coordinate and allo-

cate the inflow of energic inputs and establish the structures

necessary for the completion, evaluation, and renewal of

nursing work in production subsystems. Internal demands of

nursing production subsystems relate to the nature of the

work performed, structures arising from the division of

nursing labour, and the work conditions at the point of care.

Negative feedback includes organizational performance indi-

cators (e.g. longer than expected length of stay or time on

programme).

The dynamic interdependence among subsystems, the

organization, and the external environment is illustrated

using the example of emergency department overcrowding

and one of its proposed solutions, the introduction of nurse

practitioners. In response to pressures to reduce crowding

(i.e. external demand), subsystems would recommend and

implement the proposed solution (i.e. adaptive function); hire

the nurse practitioners (i.e. supportive function); formalize

policies to enable the work of nurse practitioners (i.e.

maintenance function); and integrate these changes across

subsystem, role, and hierarchical boundaries to ensure

stakeholder buy-in and to monitor performance (i.e. man-

agement function). The emergency department (i.e. nursing

production subsystem) would re-divide the labour to accom-

modate the new role and the work performed (i.e. internal

demands). By altering the staffing mix (i.e. inputs), service

capacity (i.e. throughput) is increased, leading to reduced

overcrowding and increased consumer satisfaction (i.e. orga-

nizational and clinical outcomes; e.g. Carter & Chochinov

2007). In turn, because nurse practitioners typically engage in

primary care and health promotion, unnecessary readmis-

sions to the emergency department could be offset in the

future (i.e. feedback cycle).

By considering the various inputs and throughputs that

influence nursing service delivery and outputs, the NSDT

proposes that nursing work in a given production subsystem

is not performed in isolation; rather, nursing work in

production subsystems is dynamically interdependent with

the other subsystems and the organization suprasystem that

interact with the external environment. There is no single

Throughput

Organization suprasystem Includes management, supportive, maintenance,

adaptive & production subsystems

• Type, size, location, structure, ideology

Nursing production subsystem

Nature of the work • Technology • Input quantity & uncertainty

Structure • Size • Role design • Staffing practices • Nursing care delivery model • Coordination mechanisms

Work conditions • Work environment • Power

Care recipient characteristics

• Demographics

• Resources

• Health

• Medical condition

• Nursing condition

• Self-mangement

Nurse characteristics • Demographics

• Profession

• Health

Other energic sources

• Materials

• Fiscal resources

• Information

OuputsInputs

Clinical outcomes • Clinical status

• Functional status

• Valuation

• Safety

Human resource outcomes

• Health

• Safety

• Profession

Organizational outcomes • Quality

• Efficiency

• Resource utilization

Figure 2 The Nursing Services Delivery Theory.

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� 2010 Blackwell Publishing Ltd 2833

way for an organization, or for nursing production subsys-

tems, to deliver nursing services effectively. The NSDT

emphasizes that a confluence of factors determines the global

work demands in the nursing production subsystem.

Components of the Nursing Services Delivery Theory

As shown in Figure 2, the delivery of nursing services in

production subsystems occurs inside the environment struc-

tured by the organization suprasystem, and is dependent on

the inflow of inputs, which include care recipients, nurses,

materials, and other energies.

Characteristics of the organizational suprasystem include

organizational type, size, location, structure, and ideology.

Type of organization can vary by healthcare sector (e.g.

acute, community or long-term care), academic affiliation, or

by funding source. Location may refer to geography (e.g.

rural, urban) or dispersion (e.g. multi-site organization,

catchment areas). Depending on the purpose of the inquiry,

organizational size can be measured as the quantity of

personnel, physical capacity, volume of inputs or outputs, or

discretionary resources of an organization (Kimberly 1976).

Organizational structure results from trade-offs between the

differentiation of work by function (e.g. nursing, pharmacy)

and the integration of work processes by programme (e.g.

cardiology, trauma; Charnes & Tewksbury 1993). This gives

rise to a continuum of functional, matrix, and programme

organizational forms (Charnes & Tewksbury 1993). Ideology

refers to the common norms and values held by the majority

of organizational members about expected member behav-

iours and the appropriateness of organizational activities and

functions (Katz & Kahn 1978).

Care recipient characteristics include demographics, health

status, resources, medical condition, and nursing condition.

Examples of demographic variables are age, gender, lan-

guage, and ethnicity. Health status includes the physiological

and psychosocial health states of the person. Resources

available to care recipients can be considered in terms of

material support (e.g. healthcare coverage) and social support

(e.g. informal caregivers). Medical condition encompasses the

number and types of medical diagnoses and co-morbidities

and severity. Nursing condition refers to the healthcare needs

of recipients that generate the demand for nursing services in

terms of complexity (e.g. number and types of nursing

diagnoses) or intensity (e.g. workload). Self-care management

involves the pre-existing knowledge, health behaviours, and

symptom management of care recipients and their informal

caregivers about the underlying health conditions.

Nurse characteristics consist of demographic, professional,

and health factors. Demographics include age and gender.

Profession reflects occupational factors such as licensure,

education, clinical expertise, experience, and employment

status. Health entails the physiological and psychosocial

health states of the nurse.

Other energic sources include materials, fiscal resources,

and information. Materials consist of equipment and

supplies. Fiscal resources refer to the budget allocated to a

production subsystem. Information can include, but is not

limited to, organizational trends and policies, new technol-

ogies, and feedback that the production subsystem imports

from other organizational subsystems.

Throughput consists of several factors. Nursing work is

performed in the production subsystem. Key factors influenc-

ing the delivery of nursing services in the production subsystem

entail the nature of the work, its structure, and its environ-

ment. Technology refers to the work performed by nurses.

Nursing work may be conceptualized as independent and

collaborative interventions that encompass ‘any treatment,

based upon clinical judgment and knowledge, which a nurse

performs to enhance patient/client outcomes’ (McCloskey &

Bulechek 2000, p. 3). In terms of the nursing work performed,

technology refers to task uncertainty (i.e. degree to which

cause and effect are analysable), instability (i.e. the degree to

which moment to moment changes in care recipient status

occur), and variability (i.e. diversity of number of different

components; Overton et al. 1977). The extent to which tasks

are interdependent (Thompson 1967) and time-constrained

(Adler 1995) is an additional dimension of work performance.

Temporal dimensions of nurses’ work (e.g. duration, tempo-

rality, timing, tempo) may also be considered (Jones 2001).

Uncertainty, instability, variability, interdependence, and

timing of nursing work and interventions are amenable to

measurement. Quantity and uncertainty of inputs also influ-

ence nursing work in the production subsystem. Input quantity

may be reflected by volumes of care recipient admissions,

visits, procedures, or patients; by number of staff or nursing

HPPD; or by fiscal resources. Input uncertainty is determined

by the number and probability of choices or alternatives in a

given situation (Argote 1982). With respect to care recipients,

uncertainty is reflected by diversity in the health conditions

and care needs of the population served and the number of

exceptional cases encountered. For example, patient flow to a

haemodialysis unit is more predictable in terms of admission

rates and patterns, service times, sequencing, and health

conditions, compared with an emergency department.

Uncertainty in staffing inputs is exemplified by, but not limited

to, nursing skill mix, team composition, the proportion of

full-time staff, and the use of overtime and agency staff to

meet demand. Uncertainty in material inputs entails changes

in the allocation of fiscal and material resources.

R.M. Meyer and L.L. O’Brien-Pallas

2834 � 2010 Blackwell Publishing Ltd

The structure of the nursing production subsystem arises

from the division and coordination of nursing work through

management subsystem decisions about size, role design,

staffing practices, nursing care delivery models, and coordi-

nation mechanisms. Size refers to the capacity to produce

services (e.g. numbers of beds or available home visits). Role

design assigns responsibility for particular tasks to distinct

job descriptions. Staffing practices refers to the ways in

which care activities and responsibilities are divided among

nurses at a micro-level based on care recipients (e.g. nurse–

patient ratios, workload scores), staff characteristics (e.g.

experience levels), or management practices (e.g. length and

scheduling of shifts). Nursing care delivery models (e.g.

team, primary or total care models) describe how nursing

work is divided and coordinated at the work group level.

Coordination entails mechanisms to standardize skills, work

processes (e.g. clinical pathways), outcomes, or communica-

tion methods (e.g. electronic health record; March & Simon

1958, Venkatraman 1994). Feedback is another coordina-

tion device that fosters the exchange of information in an

adaptive and reciprocal manner (Gittell 2002). Feedback can

occur through direct supervision, boundary spanning roles

(e.g. case managers), or teamwork (Gittell 2002). Work

conditions internal to the production subsystem encompass

the various physical, cognitive, psycho-social, and profes-

sional dimensions of the work environment that influence

professional practice (Kristensen 1999, Registered Nurses’

Association of Ontario 2008). In the systems approach,

power is typically conceptualized as a resource. Empowered

work environments are those in which all employees can

access opportunities to learn and grow and can obtain the

information, support, and resources necessary for the job

(Kanter 1977).

The outputs in NSDT reflect key outcomes of nurses’ work

and work environments. Clinical outcomes sensitive to

nursing care can be grouped along four dimensions (White

et al. 2005). Clinical status outcomes involve the control or

management of symptoms (White et al. 2005) and the

prevention of complications (Irvine et al. 1998). Functional

status outcomes encompass the physical and psychosocial

functioning and self-care abilities of the individual (White

et al. 2005). Valuation refers to care recipients’ perceptions

and appraisals of nursing care and care results (e.g. satisfac-

tion; White et al. 2005). Safety outcomes include adverse

events and complications (White et al. 2005). Human

resource outcomes are related to staff members’ physical

and mental well-being, safety (e.g. injuries, violence), and

profession (e.g. autonomous practice, work satisfaction).

System outcomes incorporate evaluations of service quality

(e.g. rates of adverse events), efficiency (e.g. target volumes,

length on service), and resource utilization (e.g. staffing

stability, costs).

Application

Examples from the empirical literature illustrate the rela-

tional structure of the NSDT using inputs, throughputs, and

outputs that are integral to nursing health services research.

In a first example, Doran et al. (2006) explored the relation-

ships between patient characteristics (i.e. inputs), nursing

interventions (i.e. throughput), and clinical outcomes (i.e.

outputs). Patient functional and cognitive status and depres-

sion (i.e. health), but not age (i.e. demographics), were

associated with the types of nursing interventions performed

(i.e. technology). Nursing interventions in turn partially

mediated the relationship between functional status at

baseline and at discharge, suggesting that other variables,

such as patients’ pre-existing health conditions and the work

of other healthcare professionals, may be also influencing

outcome achievement (Doran et al. 2006).

A second example illustrates the use of buffer inventories to

respond to unpredictable staffing needs. Float pool and agency

nurses (i.e. inputs) have the potential to lower organizational

costs (i.e. resource utilization), but may be detrimental to

clinical outcomes under certain conditions. In a study of an

intensive care unit, after controlling for the characteristics of

patients (e.g. demographics, medical condition), patients

receiving care from a higher ratio of pool and agency nurses

to permanently assigned nurses (i.e. input uncertainty) were at

significantly greater risk for blood stream infections (i.e.

clinical status; Robert et al. 2000). These authors surmised

that agency and float pool staff may receive less training with

respect to central venous catheter care and may be less familiar

with team functioning and unit practices.

A third example highlights the potential for inter-profes-

sional practice to improve care delivery. For example, in a

study of joint replacement surgery, workgroups with high

levels of teamwork were associated with improved clinical

and organizational outcomes (Gittell 2004). The work

performed was concurrent and iterative (i.e. interdependent),

involved multidisciplinary roles (i.e. variable), and was

delivered under declining lengths of stay (i.e. time con-

strained). The throughputs consisted of teamwork (i.e. coor-

dination mechanism), patient volumes (i.e. input quantity),

and a specialized patient population (i.e. low input uncer-

tainty). Outputs included patient satisfaction with care quality

(i.e. valuation) and length of stay (i.e. efficiency). After

controlling for patient demographics (i.e. patient characteris-

tics), volume enhanced the positive effects of specialization on

teamwork and on outcomes. Teamwork in turn mediated the

JAN: DISCUSSION PAPER Nursing Services Delivery Theory

� 2010 Blackwell Publishing Ltd 2835

effect of specialization on improved outcomes, suggesting that

the benefits of specialization are in part achieved through high

levels of teamwork (Gittell 2004).

In a final example, nursing work environments remain a key

priority among healthcare employers, particularly for staff

recruitment and retention in the context of nursing shortages.

A study of new nurse graduates (i.e. inputs) revealed that those

who experienced greater employee-job fit (i.e. throughput)

were more likely to report improved human resource outcomes

(i.e. outputs; Cho et al. 2006). When nurses with less than two

and a half years experience (i.e. nurse characteristics) had

access to opportunity, information, support, and resources (i.e.

power), they were more likely to perceive greater fit in terms of

workload, control, rewards, community, fairness, and values

(i.e. work environment), and in turn they reported higher work

engagement and consequently less burnout and greater orga-

nizational commitment (i.e. nurse health and profession

outcomes). These examples highlight the capability of the

overarching framework and the conceptual underpinnings of

the NSDT to support theoretical connections among distinct

streams of nursing services research related to nursing work,

work environments, and staffing variables.

Implications for nursing

The NSDT explains the contributions of the organizational

suprasystem and its subsystems to the global work demands

placed on nurses in production subsystems. To avoid a black

box approach to investigating the work of nurses, the actual

work performed (e.g. technology) by nurses at the point of

care, and not merely the structures or work conditions,

should be measured. The NSDT also integrates the nested

nature of organizational phenomena, thereby encouraging

the study of multiple levels of phenomena and the examina-

tion of cross-level effects and interactions. Because the NSDT

offers an abstracted view of the phenomena and is broad in

scope, its components cannot be tested comprehensively or

directly in any single study.

Future research can be guided by this theory to examine

how variations in inputs, throughputs, and organizational

characteristics result in optimal outputs related to nursing

services delivery. Empirical indicators need to be chosen

carefully to reflect the concepts in the NSDT. The compo-

nents of the NSDT are interactive and dynamic, not static.

Depending on the specific hypotheses to be tested, the

empirical indicators used to represent NSDT concepts may

serve as independent or dependent variables to given equa-

tions in the analytical models (Jelinek 1967). As conceptu-

alized, the input, throughput, and output components of the

NSDT are likely to be relevant across countries, cultures, and

settings because of the open system premise. However, the

measurement of phenomena (i.e. selection of empirical

indicators) may be tailored to specific countries, cultures, or

settings. The fields of organizational design and organiza-

tional behaviour can assist in building hypotheses, assuming

that the principles of open systems are upheld, to examine

why and how variations in inputs, throughputs, and supra-

system characteristics result in optimal outputs across nursing

services delivery production subsystems.

The NSDT can also be used to manage the factors

influencing nursing services delivery in organizations. Accu-

What is already known about this topic

• Because the delivery of nursing services has typically been investigated using hospital-level staffing indicators,

the underlying mechanisms by which nursing work

influences outcomes remain under-theorized and

unmeasured.

• Large-scale organizations can be conceptualized as open systems composed of interacting subsystems that

selectively import and transform energic inputs from the

external environment to produce services and products.

What this paper adds

• The healthcare organization is conceptualized as an open system characterized by energy transformation,

a dynamic steady state, negative entropy, event cycles,

negative feedback, differentiation, integration and

coordination, and equifinality.

• This theory situates the work of nursing in the production subsystems of the organization and

explicates the division and coordination of nursing

work.

• The theory gives a relational structure that reconciles how nursing work, staffing, and work environment

variables contribute to the global work demands placed

on nurses at the point of care.

Implications for practice and/or policy

• Future research can be guided by this theory to examine how variations in inputs, throughputs, and

organizational characteristics result in optimal outputs

related to nursing services delivery.

• Managers can use this theory as an overarching framework to manage the key components

conceptualized to influence the delivery of nursing

services at the point of care in organizations.

R.M. Meyer and L.L. O’Brien-Pallas

2836 � 2010 Blackwell Publishing Ltd

mulated and synthesized evidence is needed to explain the

conditions under which the delivery of nursing services in

large-scale healthcare organizations influences clinical,

human resource, and organizational outcomes.

Conclusion

Nursing health services research has often been criticized for

being atheoretical. Investigation of a wide variety of nurse

staffing and work environment indicators has contributed to

a fragmented understanding of nursing services delivery and

nurses’ work. By placing these studies in the relational

structure of the NSDT, a theoretical basis is given for

reconciling disparate streams of research. The NSDT can

facilitate the identification of unstudied gaps and the selection

of conceptually meaningful variables for future research. The

NSDT also offers managers new insights with which to

prioritize and evaluate concurrent organizational initiatives

directed at increasing nursing service efficiency, effectiveness,

and sustainability. The NSDT thus offers an overarching

theory for examining and managing the key concepts

theorized to influence the delivery of nursing services at the

point of care in large-scale healthcare organizations.

Funding

This work was supported by Doctoral Fellowships from the

Canadian Institutes of Health Research (No. 70487) and the

Nursing Health Services Research Unit.

Conflict of interest

No conflict of interest has been declared by the authors.

Author contributions

RMM and LLOBP were responsible for the study conception

and design. RMM performed the data collection and analysis

and drafted the manuscript. RMM and LLOBP made critical

revisions to the paper for important intellectual content.

LLOBP supervised the study.

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