Evolving Practice Of Nursing And Patient Care Delivery Models Essay.

Evolving Practice Of Nursing And Patient Care Delivery Models Essay.
Aims and objectives. This paper presents the Patient Care Delivery Model to illustrate interrelationships between model components and to support its application in research using advanced analytical techniques, including structural equation modelling.
Background. Many complex factors contribute to the nature of healthcare environments and to nurse, patient and system
outcomes. A better understanding of these factors and their interrelationships would provide insight for decision-makers to
develop strategies to improve outcomes. Evolving Practice Of Nursing And Patient Care Delivery Models Essay.
Design. A literature review approach was used to address the objectives.
Method. A threefold approach used existing theory to explicate a comprehensive conceptual framework, reviewed empirical
studies of the proposed relationships and considered the application of advanced analytical techniques to inform future research
directions.
Results. As per general system theory, inputs (patient, nurse and system characteristics) to the Patient Care Delivery Model interact
with throughputs (nursing interventions, work environments and environmental complexity) to produce intermediate (staffing
levels) and distal outputs (patient, nurse and system outcomes). Application of the model in research and its relevance for
healthcare settings is supported in the current literature. Statistical techniques that allow model testing and the investigation of
multiple relationships simultaneously have demonstrated the interconnections among the model components.
Conclusions. Development of the Patient Care Delivery Model is a step towards understanding work environments and providing
healthcare managers with evidence-based management tools. Formal testing of comprehensive, multilevel conceptual models will provide empirical linkages between inputs and outputs and will identify potential mediators between predictors and outcomes to offer new insight into organisational practices.
Relevance to clinical practice. A better understanding of how factors in the work environment impact clinical outcomes can
facilitate care processes in the nursing unit. Future studies using comprehensive conceptual frameworks and sophisticated analytical approaches will enhance professional nursing practice and improve clinical outcomes in healthcare organisations. Evolving Practice Of Nursing And Patient Care Delivery Models Essay.
Key words: Health Services Research, literature review, organisational behaviour, outcomes, Patient Care Delivery Model,
workforce issues
Accepted for publication: 23 May 2010
Introduction
For healthcare administrators to effectively meet the complex
needs of patients, healthcare providers and organisations,
evidence linking nursing work environments and care pro-
cesses to outcomes is needed. Nursing units (e.g. floors or
wards) do not function in isolation of the broader healthcare
organisation. Emerging evidence indicates that positive
Authors: Linda O’Brien-Pallas, PhD, RN, FCAHS, Professor,
Lawrence S. Bloomberg Faculty of Nursing, University of Toronto;
Raquel M Meyer, PhD, RN, Assistant Professor, Lawrence S.
Bloomberg Faculty of Nursing, University of Toronto; Laureen J
Hayes, RN, EdD, Research Associate, Lawrence S. Bloomberg
Faculty of Nursing, University of Toronto; Sping Wang, PhD,
Research Associate, Lawrence S. Bloomberg Faculty of Nursing,
University of Toronto, Toronto, ON, Canada
Correspondence: Laureen J Hayes, Research Associate, Lawrence S.
Bloomberg Faculty of Nursing, University of Toronto, 155 College
Street, Suite 130, Toronto, ON, Canada M5T 1P8. Telephone:
416 946 8393. Evolving Practice Of Nursing And Patient Care Delivery Models Essay.
E-mail: laureen.hayes@utoronto.ca
1640 Ó2010 Blackwell Publishing Ltd, Journal of Clinical Nursing,20, 1640–1650
doi: 10.1111/j.1365-2702.2010.03391.x
clinical, staff and organisational outcomes are influenced by
positive nursing work environments (Shields & Wilkins
2006, Verhaeghe et al. 2006, Rathert & May 2007). Appli-
cation of a systems perspective to conceptual frameworks and
methodologies offers the potential to improve the state-of-
the-science related to nursing work environments, staffing
and outcomes. This article presents the Patient Care Delivery
Model (PCDM) (O’Brien-Pallas et al. 2004b) which posits
that inputs (characteristics of patients, nurses and the system)
interact with throughputs (nursing interventions, work envi-
ronments and environmental complexity) to produce outputs
(staffing levels and patient, nurse and system outcomes). The
PCDM offers a valuable framework for managing the
delivery of nursing services and for achieving desired organ-
isational outcomes.
Aims and methods
This paper presents the PCDM from a conceptual standpoint,
demonstrating that its application in research can clarify the
dynamic multilevel relationships between nursing units and
other organisational structures. Details of variable measure-
ment are reported elsewhere (O’Brien-Pallas et al. 2004b,
Meyer et al. 2009). The specific objectives of this paper are
to: (i) describe the PCDM and its theoretical underpinnings;
(ii) illustrate interrelationships between PCDM components;
and (iii) present research findings that use structural equation
modelling (SEM) which demonstrate that this analytical
technique can test a system model and supports the relation-
ships posited in the PCDM. A better understanding of causal
links between healthy care environments and favourable
patient, nurse and system outcomes would offer healthcare
managers evidence to inform decision-making.
Relevant theoretical and empirical literature was the
primary resource used to address the objectives. Original
works were referred to in the discussion of theoretical
underpinnings of the PCDM. Library electronic database
searches (Medline, PubMed and CINAHL) were conducted
using keywords corresponding to variables of model compo-
nents (e.g. patient acuity, education level, work environment,
workload, patient mortality, adverse events and quality of
care). Studies that examined relationships between relevant
variables were selected from the past 10 years and findings
presented to demonstrate linkages that exist between com-
ponents of the PCDM. Accounts of studies that used a
comprehensive theoretical framework are highlighted, and
the application of the SEM analysis approach to examine
interdependencies between variables is considered. Attention
is drawn to the importance of future research to better
understand and enhance the professional practice and work
environments of nurses resulting in improved outcomes for
healthcare organisations.
Results
The Patient Care Delivery Model
Many factors shape healthcare environments and the perfor-
mance of healthcare organisations. Figure 1 illustrates the
key input, throughput and output factors of the PCDM.
Model components have been previously measured and tested
in hospital (O’Brien-Pallas et al. 1995, 2004b, Meyer et al.
2009) and community care (O’Brien-Pallas et al. 2001, 2002)
settings. The PCDM recognises the interdependence among
components and between components and the system as a
whole.
The PCDM draws on General System Theory (Bertalanffy
1950). Bertalanffy (1950, 1967) proposed principles related
to the structural and functional properties of phenomena. His
intent was to describe the common properties and relations of
phenomena in a way that was applicable across disciplines
(Bertalanffy 1967). A ‘system’ is an entity of interacting
elements. General System Theory recognises the hierarchical
nature of systems whereby each level of a phenomenon
comprises a ‘subsystem’ of interrelated parts. The interactions
of the subsystems or elemental parts are dynamic and
interdependent and combine to form a greater, complex
whole. Wholeness implies that an entity is a function of the
behaviours of all the elements. Although each element can be
considered separately, change in the entity is greater than the
sum of the changes amongst its elements (Bertalanffy 1950).
An entity also transitions towards a higher order; that is, a
system becomes more complex as its subsystems differentiate,
specialise and compete for resources. This process requires
that a system regulate itself through feedback in response to
subsystem interactions to attain a new stationary state
(Bertalanffy 1950).
A system transforms energy to survive and is considered
‘open’ if it allows for the continuous change, inflow and
outflow of materials with its environment (Bertalanffy 1950).
Open systems strive towards a steady state which may or may
not be achieved. The principle of equifinality specifies that the
end state of an open system can be achieved under differing
initial conditions and through differing trajectories. An open
system attempts to minimise entropy (system deterioration)
caused by irreversible processes through the transformation
of energy yielded from materials which have been harnessed
from the environment (i.e. inputs). Katz and Kahn (1978)
conceptualised large-scale organisations as open systems
comprised of supportive, maintenance, adaptive, production and management subsystems and the theoretical derivation of
the healthcare organisation as an open system is reported
elsewhere (Meyer & O’Brien-Pallas under review, Meyer
2010).
The PCDM also extends Jelinek’s (1967) work to better
understand the behaviour of the nursing unit system and the
broader components of the patient care system. According to
Jelinek, elements that make up the patient care functions
form the system. Inputs (described as resources) are trans-
formed into some level of outputs, and this transformation is
affected by other factors such as workload, organisation
characteristics and the environment (Jelinek). The endoge-
nous (dependent) variables represent the outputs or outcomes
of the system, and the exogenous (independent) variables
represent all of the other factors (related to inputs, the
organisations, workload and the environment) that in some
way affect the output(s).
The PCDM conceptualises the delivery of nursing services
on patient care units which are subsystems in the larger
hospital. Patients are cared for by groups of nurses who, in
turn, are clustered in patient care units. As opposed to a
collection of independent entities, each component in the
system influences the other components. The PCDM highlights
the interdependence and dynamic interaction between patient,
nurse, work environment and system factors and outcomes.
Input factors comprise the characteristics of patients, nurses
and the system as well as system unit behaviours.
These inputs are transformed in the patient care delivery
subsystem through the application of nursing interventions
in the context of particular work environments and in the
presence of environmental complexity to yield outputs for
the system. This transformative process is known as
‘throughput’. The throughput factors influence the relation-
ships between input characteristics and patient, nurse and
system outputs (O’Brien-Pallas et al. 2004b). Environmental
complexity is a throughput factor involving: unanticipated
and delayed events and the subsequent resequencing and
coordination where the nurse is involved; multiple and long
procedures that a function of increased patient acuity; and
the characteristics and composition of the care-giving team
(O’Brien-Pallas et al. 1997). In the work environment of the
patient care delivery subsystem, environmental complexity
and staffing decisions influence staffing utilisation, an
intermediate output. Staffing utilisation measures the rela-
tionship between workload hours and worked hours at the
unit level and reflects the extent to which a patient care unit
was staffed to meet patients’ needs for nursing care.
Typically, utilisation levels do not exceed design capacity
and effective capacity. Design capacity, which is the max-
imum output that can be attained under ideal conditions,
usually constitutes an unrealistic goal in real life employ-
ment settings (Stevenson 2009). Effective capacity, the actual
load a patient care unit can carry, is the maximum possible
output taking into account limiting factors and workplace
Patient characteristics
Demographics
Support
Health status
Symptoms
Health behaviours
Knowledge related to
condition & treatment
Medical complexity
Nursing complexity
Nursing intensity
Admission status
Nurse characteristics
Demographics
Education
Clinical expertise
Experience
Professional status
Employment status
System characteristics
Hospital location, size, type
Unit size, type, occupancy,
patient mix, nursing care
delivery model
System behaviours
Staffing assignments
Continuity of care
Resource adequacy
Patient outcomes
Health status
Medical consequences
Symptoms
Health behaviours
Knowledge related to
condition
Nurse outcomes
Burnout
Health
Professional practice
Safety
Job satisfaction
System outcomes
Quality of care
Absenteeism
Nurse turnover
Cost
Length of stay
Staffing efficacy
Patient care
delivery
subsystem
Intermediate
outputs
Staffing
utilization level
Environmental complexity
Inputs
Feedback
Through
Outputs Perceived work environment Interventions
Throughput processes result in distal outputs which
include patient, nurse and system outcomes in the PCDM.
Typical measures for patient outcomes include reduced
number of symptoms or medical consequences and improved
knowledge and behaviour in relation to health condition.
Nurse outcome measures include burnout, general health, job
satisfaction and intent to leave. System outcome measures
include length of stay, cost, absenteeism and quality of
patient care. These outputs provide feedback and reactivate
the system itself because positive outcomes in each of these
domains ensure that members of the community continue to
use the organisation’s services, staff are retained to provide
the services and the organisation’s accreditation and funding
are sustained. For example, decreased nurse absenteeism as a
system outcome has a positive impact on inputs relating to
staffing assignments and continuity of care.
Related research findings
Nurses’ work environments influence patient, nurse and
system outcomes (Shields & Wilkins 2006, Verhaeghe et al.
2006, Rathert & May 2007). Reported findings illustrate that
patient, nurse and organisational input and throughput
factors influence outcomes in patient care delivery subsys-
tems. In this paper, the influence of inputs and throughputs
on outputs will be examined. Although the dynamic interre-
lationships and feedback loops among components are not
detailed in these findings, the PCDM posits that the input and
throughput factors continually interact with each other and
the environment to produce outputs (outcomes) which
feedback into the system itself.
Patient factors and impact on outcomes
Patients enter the healthcare system with characteristics that
impact their own outcomes, care activities and use of re-
sources, as well as nurse outcomes. Increased age (Halm et al.
2005, Titler et al. 2006, Weiss et al. 2007), lack of family
support and/or living alone (Jackson 1989, Titler et al. 2006)
and inability to pay for healthcare (Carbonell et al. 2005,
Allareddy & Konety 2006) are associated with poor patient
outcomes. For example, patients with a higher family income,
greater than Grade 8 education (where Grade 12 is required
for completion of formal secondary education) and employ-
ment had better knowledge of their health condition (Hu
et al. 2006). Patient complexity has also been negatively
associated with nurse outcomes such as job satisfaction and
positively associated with job pressure, job threat and role
tension (McGillis Hall & Doran 2007). Evolving Practice Of Nursing And Patient Care Delivery Models Essay.
Patient inputs are also associated with system outcomes. For
example, patient age, gender and education have been linked
to nurse absenteeism and quality of care (Ganova-Iolovska
et al. 2009, Palnum et al. 2009). Increased severity of illness
(Carbonell et al. 2005, Allareddy & Konety 2006, Odetola
et al. 2007) and poor mental health status on admission (De
Jonge et al. 2001) impact complexity of care and utilisation of
service, thereby affecting system cost outcomes. Nursing
diagnosis is a strong predictor of hospital and intensive care
unit lengths of stay, costs and mortality (Thoroddsen &
Thorsteinsson 2002, Welton & Halloran 2005). Increased
patient acuity has been associated with suboptimal quality of
the care in acute wards (Massey et al. 2009) and with intensive
care unit mortality (Kiekkas et al. 2008).
Nurse factors and impact on outcomes
Nurse characteristics impact patient and nurse outcomes. For
instance, higher proportions of baccalaureate-prepared nur-
ses have been associated with lower 30-day hospital mortality
rates (Aiken et al. 2003, Estabrooks et al. 2005, Tourangeau
et al. 2006) as well as increased patient knowledge and re-
duced number of required visits in homecare (O’Brien-Pallas
et al. 2002). Ramanujam et al. (2008) found nurses’ educa-
tion level negatively influenced nurse perceptions of patient
safety. In this same study, nurse experience and full-time
employment positively influenced perceptions of work de-
mands and exhaustion, leading to increased depersonalisa-
tion and decreased nurse perceptions of patient safety.
However, contradictory findings have also been observed
with higher levels of nursing experience predicting fewer
patient safety occurrences (Blegen et al. 2001). In terms of
nurse outcomes, lower levels of nursing experience have been
associated with higher job tension (McGillis Hall & Doran
2007) and increased likelihood of near miss needle-stick
injuries (Clarke et al. 2002).
In addition, nurse factors contribute to organisational
outcomes such as care quality and staff retention. For
instance, younger or new nurses were more likely to report
delayed interventions, which is a measure of care quality
(O’Brien-Pallas et al. 2004c). High nurse turnover is costly
for organisations and can also negatively impact care quality
(Jones 2005, O’Brien-Pallas et al. 2008). Registered Nurses
(RNs) aged over 50 were more satisfied, more committed to
the organisation and less likely to quit than younger RNs
(Kovner et al. 2007). Similarly, nurses with longer hospital
tenure were more likely to remain employed until retirement
(Tourangeau & Cranley 2006). Evolving Practice Of Nursing And Patient Care Delivery Models Essay.Nurses employed casually in
direct care were more likely to plan to leave their current
position than their full and part time counterparts (O’Brien-
Pallas et al. 2004c).
Review Patient Care Delivery Model – literature review
Ó2010 Blackwell Publishing Ltd, Journal of Clinical Nursing,20, 1640–1650 1643
System factors and impact on outcomes
Organisational characteristics such as hospital size, bed
occupancy, unit type and care delivery model influence work
processes and outcomes. The larger the size of the hospital or
ward, the less patients reported individualised care (Shu-
llanberger 2000, Suhonen et al. 2007). Smaller nursing units
have been associated with enhanced professional nursing
practice, whereas larger nursing units have been associated
with lower nurse and patient satisfaction and higher patient
fall rates (Mark et al. 2003). Fluctuations in occupancy or
inpatient census related to resource use, staffing and bed
management may ultimately impact patient care quality and
nurse job satisfaction (Littig & Isken 2007). Evolving Practice Of Nursing And Patient Care Delivery Models Essay.Bed occupancy is
associated with falls (Al-Kandari & Thomas 2009) and
emergency department length of stay (Forster et al. 2003).
Consequences of prolonged waits and crowding in emergency
room include decreased patient satisfaction and reduced
access to healthcare (Vieth & Rhodes 2006). With regard to
unit type, nurses in paediatric units were the most satisfied,
whereas those in surgical services and emergency departments were least satisfied (Boyle et al. 2006). Compared with units with team or primary nursing, total patient care was
associated with lower job pressure (McGillis Hall & Doran
2007). Evolving Practice Of Nursing And Patient Care Delivery Models Essay.
Staffing assignments impact work processes and outcomes.
In haemodialysis units, high patient-to-RN ratios and
increased numbers of tasks left undone by RNs were
associated with an increased likelihood of dialysis hypoten-
sion, skipped dialysis treatments, shortened dialysis treat-
ments and patient complaints (Thomas-Hawkins et al. 2008).
Patients cared for on units with adequate staffing and
administrative supports were more satisfied with their care
(Vahey et al. 2004). Nurse–patient ratios have also been
associated with 30-day patient mortality (Aiken et al. 2002,
Elting et al. 2005, Estabrooks et al. 2005), risk of infection
(Hugonnet et al. 2007), incidence of adverse events in
patients (Cho et al. 2003) and failure to rescue (Aiken et al.
2002, Rafferty et al. 2007). Evolving Practice Of Nursing And Patient Care Delivery Models Essay.
Excessive workloads and lack of nursing support nega-
tively affects nurses and their ability to perform effectively.
Caring for additional patients increases the likelihood of
nurse burnout and job dissatisfaction (Aiken et al. 2002,
Vahey et al. 2004). Fair or poor general health of Canadian
nurses was related to high levels of job strain, job insecurity,
physical demands and role overload; to low levels of
supervisory and coworker support, autonomy and nurse–
physician working relations; and to working evenings
(Shields & Wilkins 2006). Similarly, lower mental health
scores in nurses were predicted by high workload and lack of
workplace support (Chang et al. 2006). Emotional exhaus-
tion because of inadequate nursing resources and excessive
workload has a negative impact on nurses’ professional
efficacy (Greenglass et al. 2001). Evolving Practice Of Nursing And Patient Care Delivery Models Essay.The use of overtime to
address inadequate nurse staffing also has negative patient
and nurse consequences including greater risk of errors
(O’Brien-Pallas et al. 2004c), emotional exhaustion (Patrick
& Lavery 2007), musculoskeletal disorders (Trinkoff et al.
2006) and RN lost-time claims (O’Brien-Pallas et al. 2004a).
Insufficient staffing resources results in unfinished nursing
tasks which lower quality of care (Sochalski 2004) and
increase organisational costs (Cho et al. 2003). In contrast,
enhanced professional nursing practice (decentralisation,
autonomy and nurse physician collaboration) has been
associated with lower nurse turnover (Mark et al. 2003). Evolving Practice Of Nursing And Patient Care Delivery Models Essay.
An adequate complement of permanent nurses on a unit is
essential for effective coordination and consistency of patient
assignments. High continuity or specialization has been
associated with lower rates of death, pneumonia and cardiac
arrest and shorter lengths of stay (Boyle 2004). Frequent use
of non-full-time and temporary staff nurses who are unfa-
miliar with the unit culture and practices threatens care
continuity and place additional pressure on the unit-
employed nurses as effective teamwork becomes more diffi-
cult (Kalisch & Begeny 2005, Grinspun 2007, Duffield et al.
2009). Also, essential in the nursing unit is support staff to
perform non-nursing tasks. When RNs were allowed to
perform in areas for which they were exclusively trained, job
satisfaction improved when staff support was sufficient
(Nathenson et al. 2007). Evolving Practice Of Nursing And Patient Care Delivery Models Essay.
Throughput factors and impact on outcomes
Throughput factors involve nursing work environments,
interventions and environmental complexity. Processes of
nursing care are a mechanism through which nurses exert an
indirect effect on patient outcomes (Thomas-Hawkins et al.
2008). Accordingly, the PCDM posits that inputs from
patients, nurses and the system interact with throughput
factors to produce outputs. For example, social support from
supervisors, rewards and control over work have been shown
to predict job satisfaction and physical demands and time
pressures contribute to emotional exhaustion (Gelsema et al.
2006) and general nurse health (Shields & Wilkins 2006).
Similarly, nurse managers’ ability and support significantly
impacted nurse burnout and job dissatisfaction and patient
30-day mortality and failure to rescue (Aiken et al. 2008).
Leadership as an important aspect of the work environment
influences ability to carry out responsibilities and patient
responses to care received. Effective nursing leadership has
been associated with staffing adequacy resulting in collabo-
rative relationships with physicians and greater nurse
L O’Brien-Pallas et al.
1644 Ó2010 Blackwell Publishing Ltd, Journal of Clinical Nursing,20, 1640–1650
involvement in unit governance, both of which were associ-
ated with a nursing (versus medical) model of care which, in
turn, had direct and indirect effects on patient safety out-
comes (Laschinger & Leiter 2006). Evolving Practice Of Nursing And Patient Care Delivery Models Essay.
Environmental complexity is the extent to which unantic-
ipated disruptions in nurses’ daily assignments impact
outcomes (O’Brien-Pallas et al. 2002). In a homecare nursing
study, unanticipated case complexity was negatively associ-
ated with client status (O’Brien-Pallas et al. 2002). Unneces-
sary delays, distractions and interruptions can interact with
inputs and care delivery processes, thereby impeding nursing
work, decreasing quality of care and negatively impacting
nurse and patient outcomes (Beaudoin & Edgar 2003, Gurses
& Carayon 2007). Nurses require adequate resources to
address unanticipated events, to maintain efficient and
effective care and to minimise negative consequences.
Intermediate outputs and impact on outcomes
In the PCDM, an intermediate output is staffing utilisation
which measures how well a nursing unit is staffed to meet
patient care standards and needs (O’Brien-Pallas et al.
2004b). Staffing levels in turn impact outcomes. Reviews of
acute care nurse staffing studies (e.g. Lang et al. 2004,
Lankshear et al. 2005, Kane et al. 2007) offer mixed support
for the associations between staffing levels and outcomes for
patients (e.g. mortality, failure to rescue, poor clinical out-
comes), nurses (e.g. burnout, job satisfaction) and the system
(e.g. increased length of stay). Considering the demand for
nursing services relative to available resources could clarify
the effects of nursing resources on outcomes.
As stated by the PCDM, the components in an open system
continuously interact with each other and the environment to
produce outputs that may be beneficial or detrimental to the
care delivery system itself. For example, the outcomes
resulting from nursing demand and resource adequacy
provide feedback to the system. Exploration and analysis of
such complex causal relationships requires statistical ap-
proaches suitable to theory testing and development.
Analytical strategy for a systems model
To achieve desired outputs in any large system that has many
subsystems, the mutual influence of subsystems on each other
and on the system as a whole must be considered. A clear
model depicting the interacting elements in a system will
facilitate a better understanding of interactions among
subsystems. The healthcare organisation involves a myriad
of interacting elements, therefore, analytical procedures are
needed that use a system approach. Health outcomes result
from a complex array of healthcare system inputs, through-
puts and outputs (O’Brien-Pallas et al. 1997, 2004b). Ana-
lytical approaches to test the PCDM that reflect an open
systems perspective will promote a better understanding of
phenomena at the individual, nursing unit and hospital levels
and shed further light on organisational functioning. To test
the PCDM and similar models, the use of statistical
techniques that allow the testing of the theoretical framework
and the investigation of multiple relationships simultaneously
is important (Mark 2006). Evolving Practice Of Nursing And Patient Care Delivery Models Essay.
The empirical literature review for this paper revealed
that the relationships between PCDM components and
outcomes have typically been investigated using traditional
modelling (i.e. least square linear regression) which tests
relationships by controlling for the effects of other variables
without accounting for clustering effects or specifying
pathways. Organisational data are often hierarchically
structured with patients and nurses nested within and
across units. When linking nursing practice to outcomes,
researchers need to use more sophisticated tools to account
for clustering effects (Lake 2006). Evolving Practice Of Nursing And Patient Care Delivery Models Essay.That is, the hierarchical
or multilevel structure of health data poses methodological
issues as clustered observations are not independent (Lake
2006). Health outcomes researchers have used hierarchical
linear modelling (HLM, or multilevel modelling) to handle
the dependency of observations (Lake 2006) and to test the
effects of variables at the individual and aggregate levels
(e.g. hospital, nursing unit). For example, HLM was used to
examine nursing work environment factors at the unit level
that may affect nurse outcomes at the individual level
(McGillis Hall & Doran 2007). Meyer et al. (2009) applied
HLM to a hierarchical data set for cardiac and cardiovas-
cular patients, nurses and units in a test of the PCDM and
concluded that patient outcomes are influenced not only by
patient and nurse characteristics but also by organisational
staffing practices. Evolving Practice Of Nursing And Patient Care Delivery Models Essay.
Although the PCDM has been tested with regular multiple
regression and HLM, neither analytical technique allows
researchers to account for pathways and simultaneous
causation in the data analysis (Violato & Hecker 2007). Evolving Practice Of Nursing And Patient Care Delivery Models Essay.
For example, a nursing unit’s behaviour is partly determined
by the hospital where it is located; therefore, it is preferable
to use a technique that simultaneously takes the intermediate
effects into account and allows an examination of important
interactions (Lake 2006, Mark 2006). SEM, a relatively new
and increasingly popular technique since its introduction in
the 1960s, is designed to test theoretical models (Burns &
Grove 2001, Norris 2001).Evolving Practice Of Nursing And Patient Care Delivery Models Essay. SEM permits the simultaneous
assessment of multiple dependent variables and both direct
and indirect effects of one variable on another (Hays et al.
2005), such as the ones posited in the PCDM (characterised
Review Patient Care Delivery Model – literature review
Ó2010 Blackwell Publishing Ltd, Journal of Clinical Nursing,20, 1640–1650 1645
by interactive and interconnected relationship among inputs,
throughputs and outputs). In addition, SEM tests the mea-
surement and theoretical models simultaneously. The mea-
surement model is a model of how theoretical constructs are
measured, describing the indicators (observed measures) of
the latent variables; and the theoretical model is a model of
the hypothesised relationships between the theoretical con-
structs, describing the direct and indirect effects among latent
variables (Norris 2001, Hays et al. 2005). SEM is most
appropriate when researchers have latent variables (e.g.
burnout) measured by several indicators and desire confir-
matory rather than exploratory modelling of a theoretical
model (Violato & Hecker 2007). Evolving Practice Of Nursing And Patient Care Delivery Models Essay.
Recent nursing studies have employed SEM in theory
testing. Laschinger and Leiter (2006) tested a theoretical
model of professional nursing work environments that linked
perceived conditions for professional nursing practice in
nursing work environments to burnout and engagement and,
subsequently, to patient safety outcomes. Evolving Practice Of Nursing And Patient Care Delivery Models Essay.SEM analysis
indicated direct and indirect relationships among work
environments, burnout and patient safety, emphasising the
linkages and dynamic relationships between variables. Evolving Practice Of Nursing And Patient Care Delivery Models Essay.The
SEM findings also showed that staffing adequacy directly
affected emotional exhaustion, that use of a nursing model of
care had a direct effect on nurses’ personal accomplishment
and that both directly affected patient safety outcomes
(Laschinger & Leiter 2006). SEM analysis of the relationship
between nurses’ perceptions of job demands and nurses’
perceptions of patient safety showed that perceived control
over work directly and indirectly related to nurse perceptions
of patient safety (Ramanujam et al. 2008). Nurses who felt in
control of their practice experienced lower levels of exhaus-
tion and increased confidence in the safety climate of their
unit. Evolving Practice Of Nursing And Patient Care Delivery Models Essay.
Mark et al. (2003) further used multilevel SEM (MSEM)
analysis approach in a study that applied Structural Contingency  Theory which proposes that organisations are most effective when the organisation’s structure (professional nursing practice) matches its context (internal and external environment). MSEM was adopted to test a causal model of the impact of context (e.g. hospital and nursing unit characteristics) on effectiveness (e.g. organisational and patient outcomes) through structure (i.e. professional practice) using multilevel data. Both direct and indirect effects of context variables were examined. The MSEM analysis showed that professional nursing practice directly impacted organisational outcomes such as work satisfaction but that it also indirectly mediated the relationship between contextual variables such as admission volatility and nursing turnover and work satisfaction outcomes (Mark et al. 2003). Evolving Practice Of Nursing And Patient Care Delivery Models Essay.

 

Discussion
Conceptual frameworks and analytical approaches applying
a systems perspective can clarify the relationships between
work environment variables and outcomes. Evolving Practice Of Nursing And Patient Care Delivery Models Essay.Throughput,
particularly at the nursing unit level, remains a ‘black box’
(i.e. the impact of internal work processes and dynamics on
front-line care delivery are not well measured or understood). Evolving Practice Of Nursing And Patient Care Delivery Models Essay.
Deliberately examining these black box mechanisms at the
point of care (i.e. at the nursing unit level rather than the
organisational level) would improve the explanatory and
predictive power of input factors on outcomes as conceptua-
lised in the PCDM. Nursing care processes are a mechanism
through which nurses exert effects on patient outcomes. Evolving Practice Of Nursing And Patient Care Delivery Models Essay.
Staffing levels are a critical aspect of nursing care delivery
that affect the ability of nurses to meet patient needs and to
promote positive outcomes. Environmental complexity in
units can be appraised by managers and factored into
decisions about the characteristics of the care team and
support staff and the ability of the team to address daily
difficulties and challenges. Evolving Practice Of Nursing And Patient Care Delivery Models Essay.
To achieve desired outcomes in any large system, the
reciprocal influences among subsystems and between subsystems and the larger system as a whole need to be considered. Evolving Practice Of Nursing And Patient Care Delivery Models Essay.
Adverse events for patients can also have financial and
efficiency consequences for organisations. Poor outputs then
feedback into the system to further impact the work
environment and care delivery processes. A clear framework
depicting the interacting elements in a system will facilitate a
better understanding of the subsystem interactions. Exami-
nation of interactions requires analytical procedures that
support a systems approach to explore work structures and
processes at the nursing unit level that contribute to patient
and organisational outcomes. Additional research is needed
on how organisational factors affect the processes of nursing
care and the interrelationships between nursing care pro-
cesses and outcomes. Appropriate application of statistical
techniques will assist in identifying the simultaneous influ-
ences of different organisational levels on patient care
processes and outcomes (Mick & Mark 2005). As Gelsema
et al. (2006) point out, inputs and outputs mutually influence
each other as demonstrated by the reverse associations
between changes in nurse health and well-being (e.g. emotional exhaustion) and changes in work conditions (e.g. job demands). Examination of competing explanations and interdependencies would help establish causal links between better care environments and more favourable patient, nurse
and system outcomes.
Health outcomes researchers are increasingly using more
sophisticated analytical tools to link nursing practice to
L O’Brien-Pallas et al.
1646 Ó2010 Blackwell Publishing Ltd, Journal of Clinical Nursing,20, 1640–1650
patient outcomes in hierarchical data sets (Lake 2006).
Studies applying SEM to examine the impact of work
environment factors have shown positive results for health- care organisations. Additional theory testing of the PCDM using SEM or MSEM will identify changes needed to improve outcomes. Continued development and formal testing of complex conceptual models will provide empirical evidence
for linkages between input factors and outcomes and will identify potential mediators between predictors and outcomes. Testing of these relationships will offer healthcare
managers evidence to inform decision making. Evolving Practice Of Nursing And Patient Care Delivery Models Essay.
Conclusion
The relationships proposed in the PCDM and the implications for healthcare settings are well supported in the current body of literature. This paper described the PCDM from a
conceptual perspective, its theoretical underpinnings and the empirical findings that demonstrate relationships between model components. Analytical approaches required to test a comprehensive, multilevel framework were highlighted. Evolving Practice Of Nursing And Patient Care Delivery Models Essay.
Although patient outcomes are a key measure of the effectiveness of hospital care in individual settings, the
PCDM emphasises the necessity of supportive working
conditions for nurses to enable good quality care. By considering work environment factors, new strategies for improved outcomes relating to quality of care, patient safety and health and nurse retention will enhance organisational effectiveness and efficiency and healthcare service utilisation.
Therefore, healthcare administrators can make evidenced-
informed decisions based on studies that conducted multilevel investigation of causal relationships, linking the practice conditions in the overall work environment to outcomes.
Ongoing measurement of this model in research and application of the findings in healthcare settings will promote positive system outcomes at all organisational levels.
Relevance to clinical practice
This paper discussed the PCDM from a conceptual stand-
point and applied pertinent literature. Practical implications
include the need for supportive work environments to enable
provision of good quality care and positive clinical outcomes.
When nursing units are inadequately staffed, the consequences include higher costs and poorer outcomes for patients and nurses. Overall costs are reduced when nurses  are retained, which is more likely in healthy environments that support professional nursing practice and nurses’ health and work-life balance. A better understanding of the impact of the work environment on clinical outcomes would foster more effective strategies in nursing units. Application of the PCDM and SEM in future studies could generate insights for management decisions relating to clinical practice in nursing units. Such research could inform necessary changes in organisational characteristics and behaviours to benefit nurses, patients and the healthcare organisation.
Nursing care delivery is defined as the way task allocation, responsibility, and authority are organized to achieve patient care. Tiedeman and Lookinland (2004) suggested that systems of nursing care delivery are a reflection of social values, management ideology, and economic considerations. (Tiedeman&Lookinland, 2004) According to Fewer (2006), the quality of nursing care delivery systems affects continuity of care, the relationship between nurse and patient, morale, nurse job satisfaction and educational preparation.(Fewer, 2006) Nurses are essential human resources to provide medical services with professional knowledge and skills in the healthcare setting. However, the registered nurse turnover rate has increased in recent years resulting in lowering morale and quality of patient care in the U.S. Various models of patient care delivery have been introduced. They include, total patient care and functional nursing, team nursing, primary nursing, nursing care management and transforming care at the bedside. These models vary in clinical decision making, work allocation, communication and management, and model choice is driven by differing social and economic forces.(Tiedeman&Lookinland, 2004) This paper examines the description and effects of the team nursing model.
Description of the Team Nursing Care Delivery Model
Research by Tiedeman, Lookinland (2004) illustrated in team nursing that the healthcare workers consist of a diversity of education, skills, licensure, professionals (RNs), technical personnel (LPNs), and ancillary staff (nurses’ aides). The team model allows the utility of nonprofessional nursing personnel such as LPNs and nursing assistants, through delegation and observation by an RN while holding a team leader accountable.( Tiedeman&Lookinland,2004) The focus is to work collaboratively and cooperatively with shared responsibilities, and to some extent accountabilities, for assessment, planning, delivering, and evaluation of patient care. ( Tiedeman&Lookinland, 2004)
In this type of nursing care model, the RN team leader has the responsibility to supervise a group of patients. The team leader assigns team members with task allocations to personnel according to roles, licensure, education, ability and the complexity of the care required. (Tiedeman&Lookinland,2004) Therefore, the team leader also needs to be aware of the legal and political limits of each role. Yoder-Wise(2011) explained that another crucial role for the team leader is to improve patient satisfaction by planning the care, delegating the work, and following up with members to evaluate the quality of care for the patients assigned to the nursing team.(p. 255) It is extremely essential for team leaders to practice effective clinical leadership in the model. Therefore, team leaders must have necessary experience, excellent nursing skills and in-depth knowledge to perform patient care and to communicate clearly with the team members. Also, the team leaders are required to be effective decision-makers and have conflict management capabilities. For the staff RN`s role and responsibility, according to Yoder-Wise(2011), ‘the staff nurses, as members of team, develop expertise in care delivery. The most educated staff is required to supervise less skilled workers, rather than providing direct care themselves.’ (p. 255) In explaining this role, staff nurses progress responsibility for significant care giving and identify nursing situations to provide support and assistance to unskilled workers especially for new graduates. As a result, nurses working in a team can better improve relationships.In team nursing, each team member delivers and provides patient care through the coordination and cooperation by delegation of assignments accordingly to the team member’s level of responsibility and accountability. For example, the RN performs the assessment and administers intravenous medications and handles the admission. Hence, LPNs may give oral medications and collect data. Nursing assistants are delegated minor duties such as hygiene tasks or personal care.
In terms of reporting relationships, according to Yoder-Wise(2011), ‘the member of a team reports directly to the team leader, who then reports to the charge nurse or unit manager hierarchically.’ (p. 254) Thus, the team leader must be higher skilled and well-trained in order to communicate between team members.
In spite of the model of care, all team members need to work within their scope of practice and be aware of the scope of their colleagues’ practices in the group. 

Cost, quality of care and patient satisfaction in a team nursing care model
According to Tiedeman and Lookinland (2004), ‘the team model is viewed as one of the most expensive models of patient care delivery because more personnel are needed. It is a less efficient model because of time spent in coordinating, delegating, and supervising leads to a loss of productive work time.’ In contrast, the functional nursing care model is more cost-effective. The model defines that fewer RNs with unprofessional workers can deliver care to a large group of patients. In spite of the financial benefits, the functional nursing model has been criticized due to crucial problems such as poor quality of care, low patient satisfaction, increased omissions and errors. Not surprisingly, nurses are enabled to provide a high quality of care to patients in team nursing. Tiedeman and Lookinland (2004) reviewed that ‘quality of care is higher with the model because the nurses have responsibility and accountability for fewer patients. The nurses know the patients better and can make assignments that best match each patient’s needs with staff abilities and skills, and provide more direction, coordination, and supervision.'(p. 294) Each member is able to approach and coordinate patient needs as well as improve continuity of care in team nursing.

 he RN to BSN program at Grand Canyon University meets the requirements for clinical competencies as defined by CCNE and AACN using nontraditional experiences for practicing nurses. These experiences come in the form of direct and indirect care experiences in which licensed nursing students engage in learning within the context of their hospital organization, their specific care discipline and their local communities. As the country focuses on the restructure of the U.S. health care delivery system, nurses will continue to play an important role. It is expected that more and more nursing jobs will become available out in the community, and less will be available in acute care hospitals. PART 1 OF THE ESSAY Write an informal presentation (550 words) to educate nurses about how the practice of nursing is expected to grow and changes. Include the concepts of continuity or continuum of care, accountable care organizations (ACO), medical homes, and nurse-managed health clinics. PART 2 OF THE ESSAY Share your presentation of informal presentation presented above with nurse colleagues on your unit or department and ask them to offer their impressions of the anticipated changes to health care delivery and the new role of nurses in hospital settings, communities, clinics and medical homes. In (825 words) summarize the responses shared by THREE NURSE colleagues and discuss whether their impressions are consistent with what you have researched about health reform. A MINIMUM OF THREE SCHOLARLY REFERENCES ARE REQUIRED FOR THIS ASSIGNMENT. While APA format is not required for the body of this assignment, solid academic writing is expected and in-text citations and references should be presented using APA documentation guidelines, which can be found in the APA Style Guide, located in the Student Success Center. This assignment uses a grading rubric. Instructors will be using the rubric to grade the assignment; therefore, students should review the rubric prior to beginning the assignment to become familiar with the assignment criteria and expectations for successful completion of the assignment. You are required to submit this assignment to Turnitin. Evolving Practice Of Nursing And Patient Care Delivery Models Essay.

WEEK 2 RUBRIC

 

Benchmark Assignment: Evolving Practice of Nursing and Patient Care Delivery Models 

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Unsatisfactory
0.00%
2
Less than Satisfactory
75.00%
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Satisfactory
79.00%
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Good
89.00%
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Excellent
100.00%
80.0 %Content  
40.0 %Informal presentation (500-700 words) to educate nurses about how the practice of nursing is expected to grow and changes. Include the concepts of continuity or continuum of care, accountable care organizations (ACO), medical homes, and nurse-managed health clinics. The presentation omits discussions of expected growth and changes in the nursing practice as it relates to concepts of continuity or continuum of care, accountable care organizations (ACO), medical homes, and nurse-managed health clinics. The presentation of expected growth and changes in the nursing practice as it relates to concepts of continuity or continuum of care, accountable care organizations (ACO), medical homes, and nurse-managed health clinics is incomplete, lacking relevant information. The presentation of expected growth and changes in the nursing practice as it relates to concepts of continuity or continuum of care, accountable care organizations (ACO), medical homes, and nurse-managed health clinics meets the basic requirements of the assignment as indicated by the assignment instructions. The presentation of expected growth and changes in the nursing practice as it relates to concepts of continuity or continuum of care, accountable care organizations (ACO), medical homes, and nurse-managed health clinics is both informative and entertaining. The presentation of expected growth and changes in the nursing practice as it relates to concepts of continuity or continuum of care, accountable care organizations (ACO), medical homes, and nurse-managed health clinics is both informative, entertaining, while demonstrating insightful understanding.
40.0 %In 800-1,000 words summarize the responses shared by three nurse colleagues and discuss whether their impressions are consistent with what you have researched about health reform. No summary provided. The summary of the responses shared by three nurse colleagues, and the discussion to whether their impressions are consistent with what you have researched about health reform is insufficient, missing relevant information. Evolving Practice Of Nursing And Patient Care Delivery Models Essay. The summary of the responses shared by three nurse colleagues, and the discussion to whether their impressions are consistent with what you have researched about health reform meets the basic requirements of the assignment as indicated by the assignment instructions. The summary of the responses shared by three nurse colleagues, and the discussion to whether their impressions are consistent with what you have researched about health reform is informative through the perspectives it offers. The summary of the responses shared by three nurse colleagues, and the discussion to whether their impressions are consistent with what you have researched about health reform is informative through the perspectives it offers, while demonstrating insightful thinking.
15.0 %Organization and Effectiveness  
15.0 %Originality The speech is an extensive collection and rehash of other people’s ideas, products, images, or inventions. There is no evidence of new thought or inventiveness. The speech is a minimal collection or rehash of other people’s ideas, products, images, or inventions. There is no evidence of new thought. The speech shows evidence of originality. While based on other people’s ideas, products, images, or inventions, the work does offer some new insights. The speech shows evidence of originality and inventiveness. While based on an extensive collection of other people’s ideas, products, images, or inventions, the work extends beyond that collection to offer new insights. The speech shows significant evidence of originality and inventiveness. The majority of the content and many of the ideas are fresh, original, inventive, and based upon logical conclusions and sound research.
5.0 %Format  
5.0 %Mechanics of Writing (includes spelling, punctuation, grammar, and language use)

 

 

 

 

Surface errors are pervasive enough that they impede communication of meaning. Inappropriate word choice and/or sentence construction are employed. Frequent and repetitive mechanical errors distract the reader. Inconsistencies in language choice (register) and/or word choice are present. Some mechanical errors or typos are present, but are not overly distracting to the reader. Audience-appropriate language is employed. Prose is largely free of mechanical errors, although a few may be present. The writer uses a variety of sentence structures and effective figures of speech.
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