Journal of Nursing Management, 2016, 24, 261–270
Two models of nursing practice: a comparative study of motivational characteristics, work satisfaction and stress 2 € ANJA RANTANEN P h D , R N 1, ANNELI PITKANEN P h D , R N , IRMELI PAIMENSALO-KARELL MARKO ELOVAINIO P h D 5 and PIRJO AALTO P h D , M B A , P T 6
BNSc, RN
3,4
,
1
University Instructor, School of Health Sciences, University of Tampere, Tampere, 2Director of Nursing, 6Chief Director of Nursing, Pirkanmaa Hospital District, Tampere University Hospital, Tampere, 3MNSc Student, Department of Nursing Science, University of Turku, Turku, 4Medical Imaging Centre, Tampere University Hospital, Tampere, and 5Research Professor, National Institute for Health and Welfare, Helsinki, Finland
Correspondence Anja Rantanen University of Tampere School of Health Sciences FI-33014 University of Tampere Finland E-mail: [email protected]
€ RANTANEN A., PITKANEN A., PAIMENSALO-KARELL I., ELOVAINIO M., AALTO P.
(2016)
Journal of Nursing Management 24, 261–270. Two models of nursing practice: a comparative study of motivational characteristics, work satisfaction and stress Aim To examine the differences in work-related motivational and stress factors between two nursing allocation models (the primary nursing model and the individual patient allocation model). Background A number of nursing allocation models are applied in hospital settings, but little is known about the potential associations between various models and work-related psychosocial profiles in nurses. Method A cross-sectional study using an electronic questionnaire. The data were collected from nurses (n = 643) working in 22 wards. In total, 317 questionnaires were returned (response rate 49.3%). Results There were no significant differences in motivational characteristics between the different models. The nurses working according to the individual patient allocation model were more satisfied with their supervisors. The work itself and turnover caused more stress to the nurses working in the primary nursing model, whereas patient-related stress was higher in the individual patient allocation model. Conclusion No consistent evidence to support the use of either of these models over the other was found. Both these models have positive and negative features and more comparative research is required on various nursing practice models from different points of view. Implications for nursing management Nursing directors and ward managers should be aware of the positive and negative features of the various nursing models. Keywords: job satisfaction, nurses, nursing work models, work stress Accepted for publication: 13 April 2015
Background The work environment in health care is characterised by rapid changes with developments in bedside technology, shortened lengths of inpatient care, the DOI: 10.1111/jonm.12313 ª 2015 John Wiley & Sons Ltd
increasing acuity of patients, consumer demands (Fairbrother et al. 2010) and the demand for providing evidence-based care (Pearson et al. 2007, ICN 2012). One approach that impacts patient, nurse and organisational outcomes is the way in which nursing practice 261
A. Rantanen et al.
is organised (Hoffart & Woods 1996), and various models for organising nursing resources to meet patient care needs have been developed (Butler et al. 2011). The models differ in work allocation, clinical decision making, communication and management (Tiedeman & Lookinland 2004). Common models have included functional nursing, team nursing, total patient care and primary nursing (Hoffart & Woods 1996, Tiedeman & Lookinland 2004, Sjetne et al. 2009) and nowadays also the relationship-based care model that includes the element of primary nursing (Jost et al. 2010, Winsett & Hauck 2011). However, in practice there is not only one theoretical way in which nurses implement nursing models; there may be different modifications (Sjetne et al. 2009, Jost et al. 2010) which may be the result of various factors, such as ward managers’ understanding of the nuances of the model (Jost et al. 2010), staff quality and quantity, type of care and ward size (Sjetne et al. 2009). The primary nursing model (PNM) has gained widespread acceptance (Sellick et al. 2003). The model was developed in the United States of America during the late 1960s and early 1970s (Pontin 1999). In PNM, one nurse is responsible and accountable for the total care of a small group of patients from the time of admission to the time of discharge (Sellick et al. 2003, Tiedeman & Lookinland 2004). The primary nurse coordinates the care of the patient. He or she assesses and prioritises the patient’s needs, plans and evaluates the care (Sellick et al. 2003, Butler et al. 2011). The primary nurse delegates the responsibility for the care of patients to associate nurses when off duty (Sellick et al. 2003, Tiedeman & Lookinland 2004). Work-related factors such as motivational characteristics, stress and job satisfaction are used when nursing practice models are evaluated. According to Hackman and Oldham (1975), skill variety, task identity, task significance, autonomy and feedback are motivational characteristics that drive people to behave in a way that directs and sustains their work behaviour. Work stress generally refers to various aspects of work environment, such as time pressure and lack of resources, difficult patients, working alone, difficult information processing systems and heavy responsibility (Harris 1989). Job satisfaction is a positive experience of and attitude towards one’s possibilities to learn and to experience professional growth, security, pay, colleagues and superiors (Hackman & Oldham 1975). Implementing the primary nursing model has been shown to improve nurses’ autonomy (Thomas 1992, 262
Melchior et al. 1999, Allen & Vitale-Nolen 2005) and to decrease their experience of work complexity (Thomas 1992, Melchior et al. 1999). On the other hand, Boumans and Landeweerd (1996) found no significant improvements in motivational characteristics such as autonomy, feedback or work complexity. The primary nursing model has not decreased burnout levels among nurses (Melchior et al. 1996) but may even result in increased levels of stress (Akinlami & Blake 1990, Webb & Pontin 1996). Some studies reported no association between stress and PNM (M€akinen et al. 2003b), while some others have reported less workrelated stress with PNM (Thomas 1992, Adams et al. 1998). A recent review suggests that PNM may increase the level of staff retention (Butler et al. 2011). Research findings have also been contradictory related to job satisfaction when implementing PNM. M€akinen et al. (2003a), Sellick et al. (2003) and Allen and Vitale-Nolen (2005) found a positive correlation between PNM and job satisfaction, while Boumans and Landeweerd (1999) as well as Sjetne et al. (2009) found no significant changes. As in the primary nursing model, one nurse is responsible for the total care of a group of patients also in the individual patient allocation model (IPAM) (Fairbrother et al. 2010), in the total patient care model (Tiedeman & Lookinland 2004, Wells et al. 2011) and in the case method model (Mohamed 2004). In these three other models, a nurse is responsible only during a shift (Mohamed 2004, Fairbrother et al. 2010, Wells et al. 2011) and not from admission to discharge as in PNM (Sellick et al. 2003, Tiedeman & Lookinland 2004). Fairbrother et al. (2010) compared IPAM and team nursing and found job satisfaction to be higher in the team nursing model. In contrast, no significant change in job satisfaction was observed in changing from the team model to the total patient care model (Wells et al. 2011). The case method model has been shown to be more fulfilling than the functional method in areas such as core job characteristics and satisfaction with the work context (Mohamed 2004). The models of nursing practice guide nurses toward professionalism and serve as a means of organising care (Jost et al. 2010). As shown, earlier research findings are contradictory. Thus, there is not enough evidence to support the use of PNM or any other model, over another. Evaluative, systematic research on the impact of the different models of nursing practice is needed (Tiedeman & Lookinland 2004). In this study, two different models of nursing practice delivered in a university hospital are compared from the nurses’ point of view. ª 2015 John Wiley & Sons Ltd Journal of Nursing Management, 2016, 24, 261–270
Two models of nursing practice: a comparative study
Aim The aim of this study was to test the differences between the primary nursing model and the individual patient allocation model in: (1) work-related motivational characteristics; (2) work-related stress factors; and (3) job satisfaction, as reported by nurses working at one university hospital.
working during other shifts; (2) a named primary nurse, but no named associate nurse working during other shifts; (3) an individual patient allocation. These models were selected because they were the most frequently mentioned in the first phase survey. The second phase’s more detailed survey indicated that models (1) and (2) were used the most, which is why these options are compared in this third phase survey. The characteristics of the wards are described in Tables 1 and 2.
Methods Study design
Participants
The study was cross-sectional. The research was carried out in one university hospital in Finland, proceeding in three phases. In the first phase, following permission from the hospital, a structured questionnaire was sent to the ward managers in somatic specialised care wards (n = 39), where they were asked to choose the right nursing practice model from five alternative models to describe the best of the nursing approach of their ward. The alternative models were: (1) a named primary nurse and a named associate nurse working in other shifts; (2) a named primary nurse but an associate nurse being on duty only during the morning shift; (3) a named primary nurse, but no named associate nurse working during other shifts; (4) an individual patient allocation; (5) some other model. In the second phase, a detailed e-mail inquiry of nursing practice models was sent to the university hospitals’ ward managers (n = 28), who had in the first questionnaire depicted the function of their ward from the following nursing practice models: (1) a named primary nurse and a named associate nurse
The data for the study were collected from the bedside nursing wards (n = 22) of one university hospital where the two most used models of nursing are conducted in the following ways: (1) a primary care nursing model in which a named primary nurse and, in addition, a named associate nurse working during other shifts (n = 8); or (2) an individual patient allocation model (n = 14). The study included 643 nurses who had been working on the ward for at least 3 months before data collection began. The data were collected during November and December 2012 using an electronic questionnaire (Webropol, www.webropol.fi) linked to the e-mail addresses of the participants. The e-mail addresses for data collection were collected from the department head nurses of the participating wards. The participating nurses responded anonymously to the study. In total, 317 questionnaires were returned, a response rate of 49.3%. Two questionnaires were rejected because the participants had not stated the ward on which they were working.
Table 1 Primary nursing wards Ward Infection inpatient ward Pulmonary inpatient ward KEI1
Pulmonary inpatient ward KEI2 Surgical inpatient ward Gastroenterological and surgical inpatient ward GAS1/KIR2 Cancer inpatient ward RS2 Intensive care of children ward Children’s inpatient ward L06
Patient profile Infection patients, every specialty covered COPD patients Shortness of breath, infections in lungs and tumour studies Pulmonary and dermatological diseases Cancer, infections Urological and vascular surgery patients Colon and anal diseases, cancer, stoma patients Inflammatory intestine diseases Cancer patients, mostly lymphoma patients Gastroenterological, cardiological, nephrological paediatric diseases Cancer and diabetes children Growth studies
ª 2015 John Wiley & Sons Ltd Journal of Nursing Management, 2016, 24, 261–270
Number of beds
Average period of treatment
22 beds 23 beds
10.4 days 6.1 days
22 beds
6.2 days
24 beds 19 beds + monitoring room 4 beds 24 beds, week-ends 12 beds 11 + 5 beds
3.1 days 5.4 days
12 beds
3.4 days
3.4 days 3.6 days
263
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Table 2 Individual patient allocation wards Ward Internal medicine treatment duty activity
Ward of internal medicine and arthritis centre Nephrological inpatient ward Haematological inpatient ward Gastrological inpatient ward
Orthopaedic inpatient ward
Hand and plastic surgery inpatient ward
Neurological inpatient ward + Neurological acute inpatient ward Stroke ward
Neurosurgery ward
Eye inpatient ward Pregnancy and birth inpatient ward 2B Pregnancy and birth inpatient ward 2A Children’s inpatient ward
Patient profile Pneumonia Pulmonary embolus Poisoning Heart failure Atrial fibrillation Need for 2-pressure way ventilator or CPAP under control Demanding internal medicine patients Endocrinology Arthritis patients Kidney patients in different stages of their disease Dialysis patients Haematological patients Upper gastrointestinal diseases (oesophagus, liver, stomach, gall bladder, bile ducts) Cancer diseases in these organs Acute trauma duty activity Bone fractures, multiple trauma patients Older patient with hip fractures Elective patients: back bone surgery, ankle, shoulder, foot, sarcoma patients Hand surgical traumas, amputations Mammary gland reconstruction Burn trauma Post-operation infections that demand wound care and operation Apoplexy patients Convulsing patients Neurological duty activity patients Apoplexy patients Convulsing patients Patients with inflammation of the brain Patients who need monitoring Patients who need thrombolytic therapy Cerebrovascular diseases Brain injuries Tumours in central nervous system Spinal cord injuries Dysfunctions in cerebrospinal fluid circulation Severe pain, epilepsy, movement disorders Eye patients Trauma, glaucoma, inflammation Mothers (regular and irregular births) and their newborn babies Mothers (born by mothers or born by section) and their newborn babies Children’s infection diseases Pulmonary diseases, pneumonia Urinary tract infections Age 0–16 years, parents are involved in care
Survey instruments Motivational characteristics The short form (Vartiainen 1989) of the job diagnostic survey (JDS) (Hackman & Oldham 1975) was used to measure the work related core motivational characteristics. The JDS measures core characteristics with 14 items. It was possible to create seven sub-areas (skills, the work as a whole, significance, autonomy, 264
Number of beds
Average period of treatment
12 at the ward + 2 in control room
2.9 days
Mon–Fri 20 beds Sat–Sun 18 beds
4.7 days
18 beds
6.1 days
20 beds 21 beds + 4-bed control ward = 25 beds
6.9 days 4.8 days
28 beds
4.1 days
23 beds
3.5 days
28 beds
4.4 days
10 beds
2.9 days
23 beds
3.6 days
6–12 beds
2.5 days
22 beds
3.4 days
23 beds
3.4 days
16 beds
3.1 days
feedback from the work, feedback from people and interaction) from the instrument, and each sub-area consisted of two items. The participants evaluated the instrument’s statements using a seven-step Likert-type scale (from 1 = not accurate to 7 = accurate). An earlier study explored the factorial validity of the job characteristics in an oncology setting. The internal consistency has been measured using Cronbach’s alpha, indicating values of 0.62–0.77 (Charalambous ª 2015 John Wiley & Sons Ltd Journal of Nursing Management, 2016, 24, 261–270
Two models of nursing practice: a comparative study
et al. 2013). In this study, Spearman’s correlations were used because the sub-areas consisted of two items. The correlation coefficients ranged from 0.14 to 0.56. Work-related stress factors The factors affecting work stress were estimated using the nurse stress index (NSI) (Harris 1989) with an edited version by Elovainio et al. (2001). Using the NSI, seven sub-areas were formed: work-related stress (five items), patient-related stress (three items), feeling of isolation (two items), information processing systems (two items), turnover (one item), competence (one item) and responsibility (one item). In addition, a total index was formed. The possible answers on the fivestep Likert scale were: 1 = very seldom or never to 5 = very often or continuously. In earlier studies reliability was determined using Cronbach’s alphas, which were at an acceptable level (Flanagan & Flanagan 2002, Kuusio et al. 2013). In this study, the Cronbach’s alphas of the subscales were 0.77 and 0.79. Two subscales (feeling of isolation and information processing systems) consisted of two items, and therefore Spearman’s correlation coefficients were determined, indicating values of 0.40 and 0.61. Job satisfaction Job satisfaction was measured using the JDS job satisfaction scale (Hackman & Oldham 1975) with 14 items. From these items, sub-areas were created to measure matters such as: growth of satisfaction (four items), permanence of employment (two items), pay (two items), colleagues (three items) and the action of supervisors (three items). The participants evaluated the items of the instrument using a seven-step Likerttype scale ranging from 1 = extremely dissatisfied to 7 = extremely satisfied. Using this instrument, the Cronbach’s alpha coefficients were 0.58 and 0.91. Spearman’s correlation coefficients were determined for the subscales: permanence of the employment (r = 0.53) and for pay (r = 0.77). Background variables were age, gender, educational background, professional title and occupational status. The ward in which the participants worked was asked for in order to allocate the nurses’ answers to the correct nursing model.
Data analysis The data were described using descriptive statistics. The differences between the background variables in the relation of diverse working models were examined ª 2015 John Wiley & Sons Ltd Journal of Nursing Management, 2016, 24, 261–270
by chi-square-test. The sum variables were formed from the instruments’ (motivational characteristics, job satisfaction and work-related stress factors) subareas. In the instrument measuring motivational characteristics, some of the items were in a negative form and they were reversed before the sum variable was formed. The variables of the sub-area were first summed and then divided by the number of variables, thus it was possible to use mean scores of the sum variables. The examination of the form of the distributions of sum variables on the basis of a histogram showed that some of the sum variables were normally distributed, whereas some were distributed skewly. Therefore a t-test was used from the parametric tests and the Mann–Whitney U test from the non-parametric tests when comparing measurable items between two groups. The limit for statistical significance was set at P < 0.05 (Polit & Beck 2004). The data were analysed using IBM SPSS Statistics for Windows, version 20.0 (IBM Corp., Armonk, NY, USA).
Ethical considerations Approval for the study was obtained from the Educational Nursing Director of the University Hospital. Oral and written information about the study was offered to nurses working in the study wards. Moreover, the participants had the opportunity to receive more information from the researchers. Participation in the study was voluntary. All responses in the third phase of the study were anonymous, and the data were treated in confidence (World Medical Association Declaration of Helsinki 2008, Medical Research Act 488/1999).
Results Participants in the study In the wards where PNM was executed, the average age of the participants was 39.9 years (SD = 12.1, range 23–66). Correspondingly, the average age was 40.5 years (SD = 11.1, range 22–61) in the IPAM wards. In both of these groups, almost every participant was female and about half of them had completed a polytechnic-level degree in nursing. More than four out of five respondents were registered nurses by occupation. Four out of five nurses had a permanent employment relationship (Table 3). Respondents in both groups considered their work as significantly influencing other peoples’ lives. A lot of interaction was included in every nurse’s work. 265
A. Rantanen et al.
Table 3 Background variables of the participants in primary care nursing model (PNM) and individual patient allocation model (IPAM)
Variable Age ≤34 35–49 ≥50 Sex Female Male Background of education Vocational degree or college degree University of applied sciences degree or higher degree of university of applied sciences or university degree Title of profession Practical nurse Registered nurse Staff nurse, substitute department head or department head nurse Occupation Permanent Not permanent
Primary care nursing model
Individual patient allocation model
n
%
n
%
P-value
55 38 32
44 30 26
73 60 51
40 33 28
0.750
125 4
96 3
170 14
92 8
0.092
57
45
80
43
0.774
70
55
105
57
7 111 11
5 86 9
10 160 15
5 87 8
0.991
98 29
77 22
138 43
76 24
0.851
Additionally, they estimated that the skills they use in nursing work varied, making it possible to use different skills and abilities. Those nurses who were acting as primary care nurses felt that they received less feedback on their success in the work done from their supervisors or colleagues, but there were no statistically significant differences between the two models compared. The nurses regarded their work as rather fragmented in both groups and were not able to do
the work from beginning to end. As a whole, the subareas of the motivational characteristics were parallel in both nursing models and no statistically significant differences were found between the two groups concerning sub-areas (Table 4). The nurses working according to PNM regarded their work as more stressful as a whole, but between the two groups there was no statistically significant difference (P = 0.136). Instead, those nurses who exercised the primary care nursing model had more workrelated stress, from pressure from work not carried out and from the quantitative inadequacy of the nursing staff, than nurses working in IPAM (P = 0.002). On the other hand, nurses who practised PNM felt less stress related to patients than nurses working in IPAM (P = 0.025). The turnover of staff caused the most stress among nurses working as primary care nurses than other participants (P = 0.003) (Table 5). In PNM wards, the nurses were more satisfied than others with the possibilities for personal growth and development offered by the work. However, there were no statistically significant differences between the groups (P = 0.155). Of the sub-areas concerning job satisfaction, in both groups the nurses were most satisfied with their colleagues and with the permanence of the employment. The nurses working in the PNM wards were more dissatisfied with their superiors than the nurses working in the IPAM wards (P < 0.001) (Table 6).
Discussion The aim of the study was to examine the differences in work-related motivational characteristics, workrelated stress factors and job satisfaction in nurses between the primary nursing model and the individual patient allocation model. The findings indicated that
Table 4 Motivational characteristics of nurses in two nursing models Primary care nursing model (n = 128–130)
Individual patient allocation model (n = 182–184)
Motivational characteristics, sub-areas
Mean
SD
Md
Q1–Q3
Mean
SD
Md
Q1–Q3
P-value
Skills The work as a whole Task significance Autonomy Feedback from the job itself Feedback from people Interaction
6.26 3.55 6.41 5.24 5.13 3.78 6.37
0.71 1.23 0.67 1.04 0.97 1.36 0.71
6.50 3.50 6.50 5.50 5.25 4.00 6.50
6.00–6.50 2.50–4.00 6.00–6.50 4.50–6.00 4.50–6.00 2.50–4.50 6.00–7.00
6.15 3.53 6.38 5.32 5.20 4.01 6.37
0.77 1.34 0.73 0.93 0.99 1.55 0.72
6.50 3.50 6.50 5.50 5.50 4.00 6.50
5.75–6.50 2.50–4.50 6.00–7.00 4.50–6.00 4.50–6.00 3.00–5.00 6.00–7.00
0.130* 0.872† 0.886* 0.536* 0.484* 0.170† 0.871*
Q1, lower quartile; Q3, upper quartile. *Mann-Whitney U. † t-test.
266
ª 2015 John Wiley & Sons Ltd Journal of Nursing Management, 2016, 24, 261–270
Two models of nursing practice: a comparative study
Table 5 Work related stress factors of nurses in two nursing models Primary care nursing model (n = 124–130)
Individual patient allocation model (n = 180–185)
P-value
Work stress
Mean
SD
Md
Q1–Q3
Mean
SD
Md
Q1–Q3
Total index Sub-areas Work-related stress Patient-related stress Isolation Information processing systems Turnover Competence Responsibility
2.98
0.49
2.93
2.60–3.33
2.89
0.50
2.93
2.60–3.20
0.136*
3.58 2.34 2.32 3.54 2.97 2.25 2.60
0.64 0.67 0.80 1.05 1.02 0.66 1.06
3.60 2.33 2.50 3.50 3.00 2.00 3.00
3.20–4.15 2.00–2.67 2.00–3.00 3.00–4.50 2.00–4.00 2.00–3.00 2.00–3.00
3.29 2.54 2.19 3.70 2.62 2.36 2.58
0.69 0.70 0.69 0.90 0.98 0.80 1.05
3.40 2.33 2.00 4.00 3.00 2.00 2.00
2.80–3.80 2.00–3.00 1.50–2.50 3.00–4.50 2.00–3.00 2.00–3.00 2.00–3.00
0.002† 0.025† 0.112† 0.292† 0.003† 0.297† 0.694†
Q1, lower quartile; Q3, upper quartile. *t-test. † Mann-Whitney U. P-values < 0.05 were considered statistically significant.
Table 6 Job satisfaction of nurses in two nursing models Primary care nursing model (n = 126–129)
Individual patient allocation model (n = 180–184)
Job satisfaction, sub-areas
Mean
SD
Md
Q1–Q3
Mean
SD
Md
Q1–Q3
P-value
Growth satisfaction Permanence of the employment Payment Colleagues Supervisor
5.70 5.76 3.52 6.08 4.56
0.74 1.18 1.59 0.51 1.38
6.00 6.00 3.50 6.00 5.00
5.25–6.25 5.00–6.50 2.00–5.00 6.00–6.33 3.67–5.67
5.57 5.65 3.50 6.02 5.00
0.78 1.19 1.55 0.51 1.38
5.75 6.00 3.50 6.00 5.33
5.00–6.25 5.50–6.50 2.00–5.00 5.67–6.33 4.33–6.00
0.155* 0.201* 0.914† 0.585*
Two models of nursing practice: a comparative study of motivational characteristics, work satisfaction and stress 2 € ANJA RANTANEN P h D , R N 1, ANNELI PITKANEN P h D , R N , IRMELI PAIMENSALO-KARELL MARKO ELOVAINIO P h D 5 and PIRJO AALTO P h D , M B A , P T 6
BNSc, RN
3,4
,
1
University Instructor, School of Health Sciences, University of Tampere, Tampere, 2Director of Nursing, 6Chief Director of Nursing, Pirkanmaa Hospital District, Tampere University Hospital, Tampere, 3MNSc Student, Department of Nursing Science, University of Turku, Turku, 4Medical Imaging Centre, Tampere University Hospital, Tampere, and 5Research Professor, National Institute for Health and Welfare, Helsinki, Finland
Correspondence Anja Rantanen University of Tampere School of Health Sciences FI-33014 University of Tampere Finland E-mail: [email protected]
€ RANTANEN A., PITKANEN A., PAIMENSALO-KARELL I., ELOVAINIO M., AALTO P.
(2016)
Journal of Nursing Management 24, 261–270. Two models of nursing practice: a comparative study of motivational characteristics, work satisfaction and stress Aim To examine the differences in work-related motivational and stress factors between two nursing allocation models (the primary nursing model and the individual patient allocation model). Background A number of nursing allocation models are applied in hospital settings, but little is known about the potential associations between various models and work-related psychosocial profiles in nurses. Method A cross-sectional study using an electronic questionnaire. The data were collected from nurses (n = 643) working in 22 wards. In total, 317 questionnaires were returned (response rate 49.3%). Results There were no significant differences in motivational characteristics between the different models. The nurses working according to the individual patient allocation model were more satisfied with their supervisors. The work itself and turnover caused more stress to the nurses working in the primary nursing model, whereas patient-related stress was higher in the individual patient allocation model. Conclusion No consistent evidence to support the use of either of these models over the other was found. Both these models have positive and negative features and more comparative research is required on various nursing practice models from different points of view. Implications for nursing management Nursing directors and ward managers should be aware of the positive and negative features of the various nursing models. Keywords: job satisfaction, nurses, nursing work models, work stress Accepted for publication: 13 April 2015
Background The work environment in health care is characterised by rapid changes with developments in bedside technology, shortened lengths of inpatient care, the DOI: 10.1111/jonm.12313 ª 2015 John Wiley & Sons Ltd
increasing acuity of patients, consumer demands (Fairbrother et al. 2010) and the demand for providing evidence-based care (Pearson et al. 2007, ICN 2012). One approach that impacts patient, nurse and organisational outcomes is the way in which nursing practice 261
A. Rantanen et al.
is organised (Hoffart & Woods 1996), and various models for organising nursing resources to meet patient care needs have been developed (Butler et al. 2011). The models differ in work allocation, clinical decision making, communication and management (Tiedeman & Lookinland 2004). Common models have included functional nursing, team nursing, total patient care and primary nursing (Hoffart & Woods 1996, Tiedeman & Lookinland 2004, Sjetne et al. 2009) and nowadays also the relationship-based care model that includes the element of primary nursing (Jost et al. 2010, Winsett & Hauck 2011). However, in practice there is not only one theoretical way in which nurses implement nursing models; there may be different modifications (Sjetne et al. 2009, Jost et al. 2010) which may be the result of various factors, such as ward managers’ understanding of the nuances of the model (Jost et al. 2010), staff quality and quantity, type of care and ward size (Sjetne et al. 2009). The primary nursing model (PNM) has gained widespread acceptance (Sellick et al. 2003). The model was developed in the United States of America during the late 1960s and early 1970s (Pontin 1999). In PNM, one nurse is responsible and accountable for the total care of a small group of patients from the time of admission to the time of discharge (Sellick et al. 2003, Tiedeman & Lookinland 2004). The primary nurse coordinates the care of the patient. He or she assesses and prioritises the patient’s needs, plans and evaluates the care (Sellick et al. 2003, Butler et al. 2011). The primary nurse delegates the responsibility for the care of patients to associate nurses when off duty (Sellick et al. 2003, Tiedeman & Lookinland 2004). Work-related factors such as motivational characteristics, stress and job satisfaction are used when nursing practice models are evaluated. According to Hackman and Oldham (1975), skill variety, task identity, task significance, autonomy and feedback are motivational characteristics that drive people to behave in a way that directs and sustains their work behaviour. Work stress generally refers to various aspects of work environment, such as time pressure and lack of resources, difficult patients, working alone, difficult information processing systems and heavy responsibility (Harris 1989). Job satisfaction is a positive experience of and attitude towards one’s possibilities to learn and to experience professional growth, security, pay, colleagues and superiors (Hackman & Oldham 1975). Implementing the primary nursing model has been shown to improve nurses’ autonomy (Thomas 1992, 262
Melchior et al. 1999, Allen & Vitale-Nolen 2005) and to decrease their experience of work complexity (Thomas 1992, Melchior et al. 1999). On the other hand, Boumans and Landeweerd (1996) found no significant improvements in motivational characteristics such as autonomy, feedback or work complexity. The primary nursing model has not decreased burnout levels among nurses (Melchior et al. 1996) but may even result in increased levels of stress (Akinlami & Blake 1990, Webb & Pontin 1996). Some studies reported no association between stress and PNM (M€akinen et al. 2003b), while some others have reported less workrelated stress with PNM (Thomas 1992, Adams et al. 1998). A recent review suggests that PNM may increase the level of staff retention (Butler et al. 2011). Research findings have also been contradictory related to job satisfaction when implementing PNM. M€akinen et al. (2003a), Sellick et al. (2003) and Allen and Vitale-Nolen (2005) found a positive correlation between PNM and job satisfaction, while Boumans and Landeweerd (1999) as well as Sjetne et al. (2009) found no significant changes. As in the primary nursing model, one nurse is responsible for the total care of a group of patients also in the individual patient allocation model (IPAM) (Fairbrother et al. 2010), in the total patient care model (Tiedeman & Lookinland 2004, Wells et al. 2011) and in the case method model (Mohamed 2004). In these three other models, a nurse is responsible only during a shift (Mohamed 2004, Fairbrother et al. 2010, Wells et al. 2011) and not from admission to discharge as in PNM (Sellick et al. 2003, Tiedeman & Lookinland 2004). Fairbrother et al. (2010) compared IPAM and team nursing and found job satisfaction to be higher in the team nursing model. In contrast, no significant change in job satisfaction was observed in changing from the team model to the total patient care model (Wells et al. 2011). The case method model has been shown to be more fulfilling than the functional method in areas such as core job characteristics and satisfaction with the work context (Mohamed 2004). The models of nursing practice guide nurses toward professionalism and serve as a means of organising care (Jost et al. 2010). As shown, earlier research findings are contradictory. Thus, there is not enough evidence to support the use of PNM or any other model, over another. Evaluative, systematic research on the impact of the different models of nursing practice is needed (Tiedeman & Lookinland 2004). In this study, two different models of nursing practice delivered in a university hospital are compared from the nurses’ point of view. ª 2015 John Wiley & Sons Ltd Journal of Nursing Management, 2016, 24, 261–270
Two models of nursing practice: a comparative study
Aim The aim of this study was to test the differences between the primary nursing model and the individual patient allocation model in: (1) work-related motivational characteristics; (2) work-related stress factors; and (3) job satisfaction, as reported by nurses working at one university hospital.
working during other shifts; (2) a named primary nurse, but no named associate nurse working during other shifts; (3) an individual patient allocation. These models were selected because they were the most frequently mentioned in the first phase survey. The second phase’s more detailed survey indicated that models (1) and (2) were used the most, which is why these options are compared in this third phase survey. The characteristics of the wards are described in Tables 1 and 2.
Methods Study design
Participants
The study was cross-sectional. The research was carried out in one university hospital in Finland, proceeding in three phases. In the first phase, following permission from the hospital, a structured questionnaire was sent to the ward managers in somatic specialised care wards (n = 39), where they were asked to choose the right nursing practice model from five alternative models to describe the best of the nursing approach of their ward. The alternative models were: (1) a named primary nurse and a named associate nurse working in other shifts; (2) a named primary nurse but an associate nurse being on duty only during the morning shift; (3) a named primary nurse, but no named associate nurse working during other shifts; (4) an individual patient allocation; (5) some other model. In the second phase, a detailed e-mail inquiry of nursing practice models was sent to the university hospitals’ ward managers (n = 28), who had in the first questionnaire depicted the function of their ward from the following nursing practice models: (1) a named primary nurse and a named associate nurse
The data for the study were collected from the bedside nursing wards (n = 22) of one university hospital where the two most used models of nursing are conducted in the following ways: (1) a primary care nursing model in which a named primary nurse and, in addition, a named associate nurse working during other shifts (n = 8); or (2) an individual patient allocation model (n = 14). The study included 643 nurses who had been working on the ward for at least 3 months before data collection began. The data were collected during November and December 2012 using an electronic questionnaire (Webropol, www.webropol.fi) linked to the e-mail addresses of the participants. The e-mail addresses for data collection were collected from the department head nurses of the participating wards. The participating nurses responded anonymously to the study. In total, 317 questionnaires were returned, a response rate of 49.3%. Two questionnaires were rejected because the participants had not stated the ward on which they were working.
Table 1 Primary nursing wards Ward Infection inpatient ward Pulmonary inpatient ward KEI1
Pulmonary inpatient ward KEI2 Surgical inpatient ward Gastroenterological and surgical inpatient ward GAS1/KIR2 Cancer inpatient ward RS2 Intensive care of children ward Children’s inpatient ward L06
Patient profile Infection patients, every specialty covered COPD patients Shortness of breath, infections in lungs and tumour studies Pulmonary and dermatological diseases Cancer, infections Urological and vascular surgery patients Colon and anal diseases, cancer, stoma patients Inflammatory intestine diseases Cancer patients, mostly lymphoma patients Gastroenterological, cardiological, nephrological paediatric diseases Cancer and diabetes children Growth studies
ª 2015 John Wiley & Sons Ltd Journal of Nursing Management, 2016, 24, 261–270
Number of beds
Average period of treatment
22 beds 23 beds
10.4 days 6.1 days
22 beds
6.2 days
24 beds 19 beds + monitoring room 4 beds 24 beds, week-ends 12 beds 11 + 5 beds
3.1 days 5.4 days
12 beds
3.4 days
3.4 days 3.6 days
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Table 2 Individual patient allocation wards Ward Internal medicine treatment duty activity
Ward of internal medicine and arthritis centre Nephrological inpatient ward Haematological inpatient ward Gastrological inpatient ward
Orthopaedic inpatient ward
Hand and plastic surgery inpatient ward
Neurological inpatient ward + Neurological acute inpatient ward Stroke ward
Neurosurgery ward
Eye inpatient ward Pregnancy and birth inpatient ward 2B Pregnancy and birth inpatient ward 2A Children’s inpatient ward
Patient profile Pneumonia Pulmonary embolus Poisoning Heart failure Atrial fibrillation Need for 2-pressure way ventilator or CPAP under control Demanding internal medicine patients Endocrinology Arthritis patients Kidney patients in different stages of their disease Dialysis patients Haematological patients Upper gastrointestinal diseases (oesophagus, liver, stomach, gall bladder, bile ducts) Cancer diseases in these organs Acute trauma duty activity Bone fractures, multiple trauma patients Older patient with hip fractures Elective patients: back bone surgery, ankle, shoulder, foot, sarcoma patients Hand surgical traumas, amputations Mammary gland reconstruction Burn trauma Post-operation infections that demand wound care and operation Apoplexy patients Convulsing patients Neurological duty activity patients Apoplexy patients Convulsing patients Patients with inflammation of the brain Patients who need monitoring Patients who need thrombolytic therapy Cerebrovascular diseases Brain injuries Tumours in central nervous system Spinal cord injuries Dysfunctions in cerebrospinal fluid circulation Severe pain, epilepsy, movement disorders Eye patients Trauma, glaucoma, inflammation Mothers (regular and irregular births) and their newborn babies Mothers (born by mothers or born by section) and their newborn babies Children’s infection diseases Pulmonary diseases, pneumonia Urinary tract infections Age 0–16 years, parents are involved in care
Survey instruments Motivational characteristics The short form (Vartiainen 1989) of the job diagnostic survey (JDS) (Hackman & Oldham 1975) was used to measure the work related core motivational characteristics. The JDS measures core characteristics with 14 items. It was possible to create seven sub-areas (skills, the work as a whole, significance, autonomy, 264
Number of beds
Average period of treatment
12 at the ward + 2 in control room
2.9 days
Mon–Fri 20 beds Sat–Sun 18 beds
4.7 days
18 beds
6.1 days
20 beds 21 beds + 4-bed control ward = 25 beds
6.9 days 4.8 days
28 beds
4.1 days
23 beds
3.5 days
28 beds
4.4 days
10 beds
2.9 days
23 beds
3.6 days
6–12 beds
2.5 days
22 beds
3.4 days
23 beds
3.4 days
16 beds
3.1 days
feedback from the work, feedback from people and interaction) from the instrument, and each sub-area consisted of two items. The participants evaluated the instrument’s statements using a seven-step Likert-type scale (from 1 = not accurate to 7 = accurate). An earlier study explored the factorial validity of the job characteristics in an oncology setting. The internal consistency has been measured using Cronbach’s alpha, indicating values of 0.62–0.77 (Charalambous ª 2015 John Wiley & Sons Ltd Journal of Nursing Management, 2016, 24, 261–270
Two models of nursing practice: a comparative study
et al. 2013). In this study, Spearman’s correlations were used because the sub-areas consisted of two items. The correlation coefficients ranged from 0.14 to 0.56. Work-related stress factors The factors affecting work stress were estimated using the nurse stress index (NSI) (Harris 1989) with an edited version by Elovainio et al. (2001). Using the NSI, seven sub-areas were formed: work-related stress (five items), patient-related stress (three items), feeling of isolation (two items), information processing systems (two items), turnover (one item), competence (one item) and responsibility (one item). In addition, a total index was formed. The possible answers on the fivestep Likert scale were: 1 = very seldom or never to 5 = very often or continuously. In earlier studies reliability was determined using Cronbach’s alphas, which were at an acceptable level (Flanagan & Flanagan 2002, Kuusio et al. 2013). In this study, the Cronbach’s alphas of the subscales were 0.77 and 0.79. Two subscales (feeling of isolation and information processing systems) consisted of two items, and therefore Spearman’s correlation coefficients were determined, indicating values of 0.40 and 0.61. Job satisfaction Job satisfaction was measured using the JDS job satisfaction scale (Hackman & Oldham 1975) with 14 items. From these items, sub-areas were created to measure matters such as: growth of satisfaction (four items), permanence of employment (two items), pay (two items), colleagues (three items) and the action of supervisors (three items). The participants evaluated the items of the instrument using a seven-step Likerttype scale ranging from 1 = extremely dissatisfied to 7 = extremely satisfied. Using this instrument, the Cronbach’s alpha coefficients were 0.58 and 0.91. Spearman’s correlation coefficients were determined for the subscales: permanence of the employment (r = 0.53) and for pay (r = 0.77). Background variables were age, gender, educational background, professional title and occupational status. The ward in which the participants worked was asked for in order to allocate the nurses’ answers to the correct nursing model.
Data analysis The data were described using descriptive statistics. The differences between the background variables in the relation of diverse working models were examined ª 2015 John Wiley & Sons Ltd Journal of Nursing Management, 2016, 24, 261–270
by chi-square-test. The sum variables were formed from the instruments’ (motivational characteristics, job satisfaction and work-related stress factors) subareas. In the instrument measuring motivational characteristics, some of the items were in a negative form and they were reversed before the sum variable was formed. The variables of the sub-area were first summed and then divided by the number of variables, thus it was possible to use mean scores of the sum variables. The examination of the form of the distributions of sum variables on the basis of a histogram showed that some of the sum variables were normally distributed, whereas some were distributed skewly. Therefore a t-test was used from the parametric tests and the Mann–Whitney U test from the non-parametric tests when comparing measurable items between two groups. The limit for statistical significance was set at P < 0.05 (Polit & Beck 2004). The data were analysed using IBM SPSS Statistics for Windows, version 20.0 (IBM Corp., Armonk, NY, USA).
Ethical considerations Approval for the study was obtained from the Educational Nursing Director of the University Hospital. Oral and written information about the study was offered to nurses working in the study wards. Moreover, the participants had the opportunity to receive more information from the researchers. Participation in the study was voluntary. All responses in the third phase of the study were anonymous, and the data were treated in confidence (World Medical Association Declaration of Helsinki 2008, Medical Research Act 488/1999).
Results Participants in the study In the wards where PNM was executed, the average age of the participants was 39.9 years (SD = 12.1, range 23–66). Correspondingly, the average age was 40.5 years (SD = 11.1, range 22–61) in the IPAM wards. In both of these groups, almost every participant was female and about half of them had completed a polytechnic-level degree in nursing. More than four out of five respondents were registered nurses by occupation. Four out of five nurses had a permanent employment relationship (Table 3). Respondents in both groups considered their work as significantly influencing other peoples’ lives. A lot of interaction was included in every nurse’s work. 265
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Table 3 Background variables of the participants in primary care nursing model (PNM) and individual patient allocation model (IPAM)
Variable Age ≤34 35–49 ≥50 Sex Female Male Background of education Vocational degree or college degree University of applied sciences degree or higher degree of university of applied sciences or university degree Title of profession Practical nurse Registered nurse Staff nurse, substitute department head or department head nurse Occupation Permanent Not permanent
Primary care nursing model
Individual patient allocation model
n
%
n
%
P-value
55 38 32
44 30 26
73 60 51
40 33 28
0.750
125 4
96 3
170 14
92 8
0.092
57
45
80
43
0.774
70
55
105
57
7 111 11
5 86 9
10 160 15
5 87 8
0.991
98 29
77 22
138 43
76 24
0.851
Additionally, they estimated that the skills they use in nursing work varied, making it possible to use different skills and abilities. Those nurses who were acting as primary care nurses felt that they received less feedback on their success in the work done from their supervisors or colleagues, but there were no statistically significant differences between the two models compared. The nurses regarded their work as rather fragmented in both groups and were not able to do
the work from beginning to end. As a whole, the subareas of the motivational characteristics were parallel in both nursing models and no statistically significant differences were found between the two groups concerning sub-areas (Table 4). The nurses working according to PNM regarded their work as more stressful as a whole, but between the two groups there was no statistically significant difference (P = 0.136). Instead, those nurses who exercised the primary care nursing model had more workrelated stress, from pressure from work not carried out and from the quantitative inadequacy of the nursing staff, than nurses working in IPAM (P = 0.002). On the other hand, nurses who practised PNM felt less stress related to patients than nurses working in IPAM (P = 0.025). The turnover of staff caused the most stress among nurses working as primary care nurses than other participants (P = 0.003) (Table 5). In PNM wards, the nurses were more satisfied than others with the possibilities for personal growth and development offered by the work. However, there were no statistically significant differences between the groups (P = 0.155). Of the sub-areas concerning job satisfaction, in both groups the nurses were most satisfied with their colleagues and with the permanence of the employment. The nurses working in the PNM wards were more dissatisfied with their superiors than the nurses working in the IPAM wards (P < 0.001) (Table 6).
Discussion The aim of the study was to examine the differences in work-related motivational characteristics, workrelated stress factors and job satisfaction in nurses between the primary nursing model and the individual patient allocation model. The findings indicated that
Table 4 Motivational characteristics of nurses in two nursing models Primary care nursing model (n = 128–130)
Individual patient allocation model (n = 182–184)
Motivational characteristics, sub-areas
Mean
SD
Md
Q1–Q3
Mean
SD
Md
Q1–Q3
P-value
Skills The work as a whole Task significance Autonomy Feedback from the job itself Feedback from people Interaction
6.26 3.55 6.41 5.24 5.13 3.78 6.37
0.71 1.23 0.67 1.04 0.97 1.36 0.71
6.50 3.50 6.50 5.50 5.25 4.00 6.50
6.00–6.50 2.50–4.00 6.00–6.50 4.50–6.00 4.50–6.00 2.50–4.50 6.00–7.00
6.15 3.53 6.38 5.32 5.20 4.01 6.37
0.77 1.34 0.73 0.93 0.99 1.55 0.72
6.50 3.50 6.50 5.50 5.50 4.00 6.50
5.75–6.50 2.50–4.50 6.00–7.00 4.50–6.00 4.50–6.00 3.00–5.00 6.00–7.00
0.130* 0.872† 0.886* 0.536* 0.484* 0.170† 0.871*
Q1, lower quartile; Q3, upper quartile. *Mann-Whitney U. † t-test.
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Two models of nursing practice: a comparative study
Table 5 Work related stress factors of nurses in two nursing models Primary care nursing model (n = 124–130)
Individual patient allocation model (n = 180–185)
P-value
Work stress
Mean
SD
Md
Q1–Q3
Mean
SD
Md
Q1–Q3
Total index Sub-areas Work-related stress Patient-related stress Isolation Information processing systems Turnover Competence Responsibility
2.98
0.49
2.93
2.60–3.33
2.89
0.50
2.93
2.60–3.20
0.136*
3.58 2.34 2.32 3.54 2.97 2.25 2.60
0.64 0.67 0.80 1.05 1.02 0.66 1.06
3.60 2.33 2.50 3.50 3.00 2.00 3.00
3.20–4.15 2.00–2.67 2.00–3.00 3.00–4.50 2.00–4.00 2.00–3.00 2.00–3.00
3.29 2.54 2.19 3.70 2.62 2.36 2.58
0.69 0.70 0.69 0.90 0.98 0.80 1.05
3.40 2.33 2.00 4.00 3.00 2.00 2.00
2.80–3.80 2.00–3.00 1.50–2.50 3.00–4.50 2.00–3.00 2.00–3.00 2.00–3.00
0.002† 0.025† 0.112† 0.292† 0.003† 0.297† 0.694†
Q1, lower quartile; Q3, upper quartile. *t-test. † Mann-Whitney U. P-values < 0.05 were considered statistically significant.
Table 6 Job satisfaction of nurses in two nursing models Primary care nursing model (n = 126–129)
Individual patient allocation model (n = 180–184)
Job satisfaction, sub-areas
Mean
SD
Md
Q1–Q3
Mean
SD
Md
Q1–Q3
P-value
Growth satisfaction Permanence of the employment Payment Colleagues Supervisor
5.70 5.76 3.52 6.08 4.56
0.74 1.18 1.59 0.51 1.38
6.00 6.00 3.50 6.00 5.00
5.25–6.25 5.00–6.50 2.00–5.00 6.00–6.33 3.67–5.67
5.57 5.65 3.50 6.02 5.00
0.78 1.19 1.55 0.51 1.38
5.75 6.00 3.50 6.00 5.33
5.00–6.25 5.50–6.50 2.00–5.00 5.67–6.33 4.33–6.00
0.155* 0.201* 0.914† 0.585*
