Characteristics of Nursing Practice Models Barbara A. Mark, PhD, RN Are there differences among the nursing practice dimensions of the three major nursing practice models—team nursing, case management, and total patient care? The author, whose study found few differences, discusses reasons for the similarity among models and suggests approaches to designing future nursing practice models. Since the 1950s, nursing administrators have searched for an ideal nursing practice model, one that would yield quality patient care, satisfied nurses, and reasonable costs. Team nursing, primary nursing, case management, each in turn has been hailed as the solution to the problem of how to organize care on nursing units. Yet extensive research on the comparative merits of nursing practice models has yielded no consistent results with regard to quality of care and patient satisfaction,1"12 nurse satisfaction,6'12"16 or costs.4'5'8'12'17"20 One reason for the inconsistency is that distinctive characteristics of practice models have not yet been identified. Without assurance that distinct practice models are in place on nursing units,21 evaluating the effects of different practice models on outcomes such as quality of care, satisfaction, and costs is likely to yield invalid findings. In the late 1970s, Munson et al.22'23 at the University of Michigan, attempted to clarify the definition and measurement of the characteristics of various practice models in nursing. Practice model was conceptualized as a "link between problems as presented by differing patient populations, and purposes as expressed by professional standards and purposes of the hospital organization." 22 ^ 24 ^ The researchers suggested that regardless of what practice model was used, or what the model was called, three underlying dimenBarbara A. Mark, PhD, RN, Associate Professor and Chair, Department of Nursing Administration and Information Systems, School of Nursing, Medical College of Virginia, Virginia Commonwealth University, Richmond.
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sions should be consistent with the patient characteristics, nursing resources, and organizational support available to a nursing unit. These dimensions were 1) the degree of integration of nursing care given a patient; 2) the degree of continuity of nursing personnel providing care for a patient; and 3) the type of coordination used to plan and organize a patient's nursing care. (Table 1 defines the basic elements of each dimension.) For example, on units where there are few registered nurses relative to nonregistered nurse staff, as might occur on a unit practicing functional or team nursing, "plan do integration"* would probably be low, whereas on a total patient care or primary nursing unit, with more registered nurses on the staff, plan do integration would be higher. Similarly, care management continuity across settings would probably not be evident in either functional or team nursing, but might be apparent in primary nursing and certainly would be an important part of case management. Despite the fact that more than 10 years have passed since the Michigan study was published, distinguishing characteristics of nursing practice models have yet to be identified. Using the dimensions outlined by Munson et al., the study reported here was designed to identify the distinctive characteristics of different nursing practice models.
Setting and Sample A purposive sample of seven general medical-surgical nursing units in four acute care hospitals in a southwestern city was selected based on an evaluation by the director of nursing or the director of research regarding the practice model utilized on the unit. There were two case management units, * "Plan do integration" is the term used by the researchers at the University of Michigan. It refers to the integration of care planning; "plan"-ning with care giving, ie, the "do"-ing of care.
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two total patient care units, and three units that used team nursing to varying degrees. None of the directors could identify a primary nursing unit for inclusion in the study. Permission to conduct the study was obtained from all hospitals and all individuals who participated and standard informed consent procedures were followed. The researcher met with nursing staff members at each hospital to explain the purpose of the study and answer questions. In each hospital, written questionnaires were distributed to all registered nurses with more than 3 months of experience working on a unit, with instructions to return the questionnaires within 2 weeks. Of
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115 questionnaires distributed, 53 were returned, for an overall response rate of 46%. Response rates varied from a high of 70% on a total patient care unit to a low of 27% on a team nursing unit.
Instrumentation Nursing Practice Dimensions The original study at the University of Michigan involved extensive and time-consuming data collection from staff nurses, head nurses, and patient records. For the current study, the data collection process was substantially modified so that data could be obtained easily and quickly from staff
JONA • Vol. 22, No. 11 • November 1992
JONA • Vol. 22, No. 11 • November 1992
sions should be consistent with the patient characteristics, nursing resources, and organizational support available to a nursing unit. These dimensions were 1) the degree of integration of nursing care given a patient; 2) the degree of continuity of nursing personnel providing care for a patient; and 3) the type of coordination used to plan and organize a patient's nursing care. (Table 1 defines the basic elements of each dimension.) For example, on units where there are few registered nurses relative to nonregistered nurse staff, as might occur on a unit practicing functional or team nursing, "plan do integration"* would probably be low, whereas on a total patient care or primary nursing unit, with more registered nurses on the staff, plan do integration would be higher. Similarly, care management continuity across settings would probably not be evident in either functional or team nursing, but might be apparent in primary nursing and certainly would be an important part of case management. Despite the fact that more than 10 years have passed since the Michigan study was published, distinguishing characteristics of nursing practice models have yet to be identified. Using the dimensions outlined by Munson et al., the study reported here was designed to identify the distinctive characteristics of different nursing practice models.
Setting and Sample A purposive sample of seven general medical-surgical nursing units in four acute care hospitals in a southwestern city was selected based on an evaluation by the director of nursing or the director of research regarding the practice model utilized on the unit. There were two case management units, * "Plan do integration" is the term used by the researchers at the University of Michigan. It refers to the integration of care planning; "plan"-ning with care giving, ie, the "do"-ing of care.
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two total patient care units, and three units that used team nursing to varying degrees. None of the directors could identify a primary nursing unit for inclusion in the study. Permission to conduct the study was obtained from all hospitals and all individuals who participated and standard informed consent procedures were followed. The researcher met with nursing staff members at each hospital to explain the purpose of the study and answer questions. In each hospital, written questionnaires were distributed to all registered nurses with more than 3 months of experience working on a unit, with instructions to return the questionnaires within 2 weeks. Of
58
115 questionnaires distributed, 53 were returned, for an overall response rate of 46%. Response rates varied from a high of 70% on a total patient care unit to a low of 27% on a team nursing unit.
Instrumentation Nursing Practice Dimensions The original study at the University of Michigan involved extensive and time-consuming data collection from staff nurses, head nurses, and patient records. For the current study, the data collection process was substantially modified so that data could be obtained easily and quickly from staff
JONA • Vol. 22, No. 11 • November 1992
