Abstract and Introduction
Abstract
Objective. To examine the associations of four distinct nursing care organizational models with patient safety outcomes.
Design. Cross-sectional correlational study. Using a standardized protocol, patients' records were screened retrospectively to detect occurrences of patient safety-related events. Binary logistic regression was used to assess the associations of those events with four nursing care organizational models.
Setting. Twenty-two medical units in 11 hospitals in Quebec, Canada, were clustered into 4 nursing care organizational models: 2 professional models and 2 functional models.
Participants. Two thousand six hundred and ninety-nine were patients hospitalized for at least 48 h on the selected units.
Main Outcome Measure. Composite of six safety-related events widely-considered sensitive to nursing care: medication administration errors, falls, pneumonia, urinary tract infection, unjustified restraints and pressure ulcers. Events were ultimately sorted into two categories: events 'without major' consequences for patients and events 'with' consequences.
Results. After controlling for patient characteristics, patient risk of experiencing one or more events (of any severity) and of experiencing an event with consequences was significantly lower, by factors of 25–52%, in both professional models than in the functional models. Event rates for both functional models were statistically indistinguishable from each other.
Conclusions. Data suggest that nursing care organizational models characterized by contrasting staffing, work environment and innovation characteristics may be associated with differential risk for hospitalized patients. The two professional models, which draw mainly on registered nurses (RNs) to deliver nursing services and reflect stronger support for nurses' professional practice, were associated with lower risks than are the two functional models.
Introduction
There is growing evidence that how nursing workers are organized and how care is provided are critical factors determining patient outcomes in hospitals. However, reports and studies in recent decades have shown that nurses often practice under suboptimal organizational conditions in terms of staffing, organization of work and the work environment. When making decisions regarding these conditions, health-care leaders assume that care can be organized under different models, but the literature is inconclusive regarding which approaches maximize nursing services' quality and safety. We target this gap by assessing the associations of four distinct nursing care organization models with patient safety outcomes.
The first step in evaluating different nursing care organization models is to define them operationally. Over the past five decades, typologies of nursing care models in hospitals have focused on allocation of patient care tasks. Four basic models are often identified: functional nursing, total patient care, team nursing and primary nursing. Limitations and inconsistencies in the use of these descriptors have been documented, and many consider them inadequate for depicting the multiplicity of actual nursing work organization models in practice. We recently developed a taxonomy of nursing care organization models that incorporated a broader range of attributes than found in the literature to date. We propose that a nursing care delivery model consists of five key dimensions: staffing intensity (measured by number of nursing care hours per patient day), skill mix [measured by proportion of care hours provided by registered nurses (RNs) and nurses holding baccalaureate (university) degrees, scope of practice (measured by the ASCOP tool that assesses the extent to which RNs apply their professional preparation in six domains of practice: assessment and planning, teaching, communication, supervision, quality of care and knowledge updating)], nursing practice environment (measured by five subdimensions of the Nursing Work Index: nurse participation in hospital affairs, nursing foundations for quality, nurse manager leadership and support, resource adequacy and nurse–physician relations) and unit-level capacity for innovation (measured on five criteria: expanded RN roles, sharpened focus of care on the patient, attention to patient transitions, leveraging of technologies and performance monitoring and feedback). Four models derived from this taxonomy are described briefly in the Methods section.
Outcomes used to evaluate care models must be sensitive to nursing inputs and interventions. Although care provision always involves different provider groups, there is increasing evidence that some outcomes, particularly those linked to safety, reflect differences in processes and structural features of nursing services. Studies have demonstrated conceptual, clinical and empirical links between nursing factors and specific safety outcomes, including medication administration errors, falls, pressure ulcers, urinary tract infections, pneumonia and unjustified restraint use. Based on this evidence, we examined a composite of these safety-related outcomes as the dependent measure in this study.