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DNP 840 Topic 3 Discussion Question Two
DNP 840 Topic 3 Discussion Question Two
How might health care leaders determine appropriate nursing and care delivery models to address rapidly changing populations?
The organization of care delivery is determined by a variety of factors such as economic issues, leadership beliefs, and the ability to recruit and retain staff. Ideally, evidence of the effect of care models on quality and patient safety would also be a major factor in decisionmaking.
Historically, four traditional care models have dominated the organization of inpatient nursing care. Functional and team nursing are task-oriented and use a mix of nursing personnel; total patient care and primary nursing are patient-oriented and rely on registered
nurses (RNs) to deliver care.1, 2 In the late 1980s, a number of nontraditional nursing care delivery models emerged that use various mixes of licensed and unlicensed nursing personnel.3–5
Care models do not exclusively pertain to the organization of nursing care, however, or the inpatient setting. Models have been examined for medical housestaff,6 pharmacy services,7 and social workers.8 They have been considered for ambulatory care,9–12 home care,13–15 and nursing homes.16 Care models also exist for specific patient populations such as elderly patients,17–20 people with mental health needs,21 and individuals with chronic conditions22 to include disease management models23, 24 and the use of technology.25
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Despite the interest in a variety of care models, it is difficult to discern which models work best. Neither the traditional nor the nontraditional inpatient nursing care models have been evaluated rigorously for their effects on patient safety.2, 4, 26 Emerging models from other care disciplines, other settings, and particular patient populations are also lacking rigorous empirical assessments of their relationship to patient safety.
A number of investigations examining care models addressed nurses’ perceptions of the care model.1, 27–38 Only two investigations combined the nurses’ perceptions with patient safety measures.39, 40
Several studies did not meet the criteria for inclusion in this review, largely due to weak designs. Of these, some reported pilot data,6, 7, 13, 24, 41, 42 some were quality-improvement projects,14, 17, 43 and others used qualitative methods.32, 36,44–48 Like the quantitative studies, the rigor of the qualitative investigations varied. However, these qualitative studies illuminate important aspects of care models not evident in quantitative investigations. For example, Ingersoll32 and Redman and Jones36 were among the first investigators to assess the effects of patient-centered care models on nurse managers. The data from both of these studies expose the pressure and role confusion experienced by nurse managers. Subsequently, a quantitative investigation found nurse managers experienced a high level of emotional exhaustion, a key component of burnout.49
Among the quantitative studies of care models included in the evidence table, only one used a design that combined systematic review and meta-analytic techniques.23 No randomized controlled trials were identified. The remaining seven studies used Level 3 designs. In two of these studies, large databases were used to examine different care models for home-based long-term care15 and mental health services.21
All five studies of nursing care models meeting inclusion criteria focused on acute care work redesigns in which the mix of nursing personnel was altered in some way. For each of these five investigations, data were reported from only one hospital.39, 40, 50–52 Of these studies, one evaluated changes in care delivery models at one university teaching hospital with two campuses in the same city.39 The remaining studies were smaller in scale focusing data collection on one,50, 51 two,52 or three units40 in the same facility. Most often, measurements were done at three points in time—pre-implementation, and at 6 and 12 months after the model was introduced.
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