coordinating care delivery models 9

Coordinating Care Delivery Models 9

CHAPTER II: LITERATURE REVIEW

Evolution of Nursing Care Models

The purpose of this literature review is to examine the evolution of nursing

care delivery models in the United States and the relevant economic, societal, or

demographic historical trends that have influenced the development of nursing

education and had a cumulative impact upon nursing practice in inpatient health care

settings. In addition, the interdependence that exists between historical trends,

nursing education, nursing research and nursing practice is examined.

The remainder of the review is divided into seven major sections, each of

which is organized around a period of time wherein a new care delivery model or

practice model evolved and changed the method for the delivery of nursing care.

Each of the sections is comprised of four interconnecting subsections. The first

subsection contains a review of relevant historical and health care background that

provides the context for changes that have evolved in nursing education and practice.

The second subsection highlights relevant developments within nursing education that

ultimately have changed nursing care delivery models. There is an emphasis upon the

development of nursing theories, which have defined the role of the nurse and the

importance of the nurse-patient relationship as the central concept of professional

nursing practice. The third subsection is focused on describing the evolution of new

nursing care delivery models, with particular attention to how care coordination has

evolved in each of the models, and the changes that have occurred within nursing

practice due to internal and external factors. In each fourth subsection, there is a


summation of the relevant internal and external factors that have impacted on the way

in which hospital nursing administrators organized patient care delivery, along with

advantages and disadvantages of each care delivery model.

Total Patient Care (Prior to 1940)

Relevant Health Care Background

In the 1930s, Americans began to buy individual health insurance, which

covered only acute services. Hospital services were expanded to meet the increasing

demand and focused on the areas of acute medicine, surgery, obstetrics, and

pediatrics. Initially, local and state government involvement in health care was

limited mainly to providing marginal care for the poor, the insane, those with

dangerous infectious diseases, and patients too acutely ill to be cared for in the home.

Except for military hospitals and a few public health service hospitals, the federal

government had almost no responsibility in health care for hospitalized patients

(Lynaugh, 1992).

In 1935, the federal government passed the Social Security Act, which has

ultimately served as the basis for most of the national health and social welfare

programs in this country. The Department of Health and Human Services is

responsible for oversight of the multiple federal agencies that administer our national

health care programs. The Social Security Act is composed of multiple titles or

components that cover a broad spectrum of programs, such as the Federal Insurance

Contributions Act (FICA) and Old Age, Survivors and Disability Insurance (OASDI)

(Kelly & Joel, 1996). Nursing leaders from the American Nurses’ Association and


the National Organization of Public Health Nurses lobbied for the inclusion of

national health insurance in the Social Security Act, but their efforts were not

successful due to the lack of broad political support and opposition from powerful

provider groups (Woods, 1996).

The American public viewed health care professionals, and especially

physicians, as unquestionable experts. There was a general belief that “the doctor

knows best” and patients signed general releases and permits for treatment on

admission to a hospital without reading them thoroughly. Although the signing of the

first Pure Food and Drug Act by Theodore Roosevelt in 1906 is considered the

beginning of the consumer revolution, there was little public interest in having an

active role in health care decisions until the 1950s (Kelly & Joel, 1996).

The creation of the Social Security Act and its components provided many

aged and disabled individuals with the health insurance to utilize local hospitals,

which increased the demand for nurses. The American public’s expectations that

health care workers would be knowledgeable and would provide health care during

times of illness provided further incentives for the development of nursing as a

vocation.

Evolution of Nursing

Although there had been numerous nurse and midwife training programs in

the United States prior to the Civil War, in 1872 the New England Hospital for

Women and Children became the first graded program established to teach scientific

nursing according the guidelines set by Florence Nightingale. Multiple other schools


followed that were founded on much the same principles (Kelly, 1987). Several of

the initial schools began as independent facilities, which were affiliated with

hospitals. Eventually they were absorbed into these hospitals because of a lack of

private funds. Students in these training programs provided the majority of nursing

care to hospitalized patients. Nursing leaders were concerned with this arrangement

because nursing education was progressing in a direction, i.e., on an apprenticeship

basis, that was contrary to the development of other professions wherein specialized

education was a prerequisite (Lynaugh, 1992; Vogt, Cox, Velthouse, & Thames,

1983).

The increased demand for nurses throughout the United States and the growth

in the number of nursing schools was derived from the rapid proliferation of small,

local hospitals between 1890 and 1940. Nursing programs were so successful and

their graduates were in such demand that a dramatic increase in hospital-based

training programs resulted: there were 15 nursing schools in existence by 1880; 432

by 1900; and 1,105 by 1909 (Kelly, 1987).

Advancement in nursing led to an expansion in function, size of work force,

and responsibilities. The purposes of nursing, and medicine, were expanded to

include both prevention and the cure of disease. The American Red Cross and public

health nursing were created. The American Nurses’ Association was formed in 1911

to facilitate the continued growth of professional nursing (Vogt et al., 1983).

A few graduate-trained nurses, who had administrative and educational

talents, functioned as head nurses, supervisors, or superintendents in hospitals.


Nursing staffs, with only a few registered nurses, were composed almost entirely of

student nurses who provided totally free labor (Kelly, 1987; Marquis & Huston, 1996;

Sullivan & Decker, 1997). During the era of hospital and nursing school growth,

graduate-trained private duty nurses cared for the majority of wealthy and middle

class patients within their own homes (Lynaugh, 1992).

During this time, nursing practice and nursing education became increasingly

intertwined. Most nursing leaders who were in supervisory positions in hospitals also

held dual positions as nursing school superintendents. The position of nursing school

superintendent was taken seriously because nursing students were providing the

majority of the nursing care within the hospital setting (Kelly, 1987; Marquis &

Huston, 1996; Sullivan & Decker, 1997). A relatively small number of experienced

nursing administrators needed to be able to closely supervise the nursing care

provided by student nurses, who were inexperienced and constantly changing. This

was accomplished through the use of a centralized care delivery model, that is, total

patient care (Lynaugh, 1992).

Total Patient Care Delivery Model

Since the 18th century, total patient care has been practiced both in patients’

homes and in hospitals. Total patient care, which is also referred to as case method

nursing, is the oldest mode of organizing patient care and was utilized exclusively

until the early 1940s (Marquis & Huston, 1996). Within this model, a registered

nurse is accountable for all aspects of the nursing care that are delivered to one or

more patients for an entire shift. The nurse works directly with the physician, patient,


family, and other health care workers to develop a plan of care. Theoretically, the

total patient care method provides the opportunity for the nurse to develop a nurse-

patient relationship and to deliver comprehensive, unfragmented care (Kron & Gray,

1987). In reality, development of a nurse-patient relationship was considered to be a

mechanism to facilitate the delivery of physical care (Ramos, 1992).

In the hospital setting, the unit head nurse makes the staff assignments,

receives each nurse’s report, and reports to the next shift. Although some head nurses

try to coordinate the care over a 24-hour period, usually each person is responsible for

the care delivered during the assigned shift and can choose to be task-centered or

patient-centered (Kron & Gray, 1987; Sullivan & Decker, 1997). The charge nurse

may also be held accountable for coordination of care (Kron & Gray, 1987).

According to Marquis and Huston (1996), the total patient care method of care

delivery is still used in some hospitals and home care agencies. It is seen as

advantageous that the assignment of nurses is a simple and straightforward process

and the nurses’ responsibilities are clear. When staffing is adequate, both nurses and

patients express satisfaction with this method of care delivery (Kron & Gray, 1987).

In the hospital setting, the head nurse gives report to the next shift and, unlike

home nursing’s traditional total care method, there is little direct communication

between caregivers. With little communication occurring between the nurses

providing patient care, fragmentation can occur due to differences in care delivery

philosophies, amount of nursing experience, or competency levels. The model also

has been criticized because registered nurses provide all the care and perform tasks


that could be done effectively by unlicensed personnel (Kron & Gray, 1987; Marquis

& Huston, 1996).

Summary

The number of hospitals being built in the early 1900s increased rapidly and

subsequently increased the demand for nurses. Many hospitals started training

programs for nurses in order to meet their need for an adequate number of nursing

students and nursing graduates to provide nursing care. Nursing supervisors

endeavored to adapt the total patient care delivery model, which had long been used

in the home setting, to provide nursing care in a hospital setting, using student nurses

to provide the care.

The total patient care delivery model that had been used to provide nursing

care in the home setting also was found to be a relatively easy method for delivering

patient care in the inpatient setting. It is ideally suited to the home care environment,

where one nurse is responsible for all nursing care for a shift and can report off

directly to the nurse responsible for the succeeding shift. In the inpatient setting, it

was found that its effectiveness could vary considerably according to the nurse

assigned for the shift and the complexity of patient care needs.

Total patient care within the home setting is a simple coordination of care

model. The assigned nurse for each shift coordinates meeting the patient’s needs and

is accountable for the outcomes of the nursing care provided during that shift. A

more complex coordination of care model is required within the hospital setting. The

assigned nurse remains responsible for nursing care provided during the shift. The


charge nurse is responsible both for coordination of work among staff nurses and for

ensuring coordinated care (Kron & Gray, 1987). Due to the shift transition

communication occurring through the charge nurse, total patient care in the hospital

has been less conducive to effective communication or continuity of care among

multiple nursing team members.

Functional Nursing (Early 1940s)


The economic depression of the 1930s and World War II eroded Americans’

confidence in the localized, private approach to health care. As a result of the

national nursing shortage caused by World War II, hospitals were in crisis (Kelly,

1987; Vogt et al., 1983).

Due to the acute wartime nursing shortage, the Office of Civilian Defense and

the American Red Cross trained more than 20,000 aides during the war, first for non-

nursing tasks and later to assist with basic nursing tasks (Kelly, 1987). The

government responded to the postwar demand for increased hospital services by

instituting the Hill-Burton Act of 1946, which provided resources to finance the

building of new hospitals and the reconstruction of pre-existing hospitals (Lynaugh,

1992).


The demand by the armed services for nurses both overseas and at home

depleted the supply of nurses and caused a change in the composition of nursing

staffs. Semiprofessionals, i.e., licensed practical nurses (LPNs), and unlicensed


assistive personnel (UAPs) were hired and trained to do certain tasks. The care needs

of the patient population were divided into required tasks per inpatient unit and the

tasks were then assigned to each staff member according to job description. Staff

gained competency through repetition of these tasks (Marquis & Huston, 1996;

Sullivan & Decker, 1997). The extreme demand for nurses led to an expansion of

nurses’ roles and a change in the skill mix of staff and the nursing care delivery model

that was utilized to provide nursing care Vogt et al., 1983).

Out of necessity, nurses who served in the armed forces during wartime were

required to assume additional responsibilities and duties that had previously been

prohibited. For the first time, the government recognized registered nurses as having

specialized skills and became concerned with their advancement (Vogt et al., 1983).

Even though young women were encouraged to enter nursing, there were not enough

nurses to meet the demand on either the home front or the battlefield (Kelly, 1987).

The increased public and government awareness about the importance of having

skilled nurses enabled nursing leaders to effectively exploit the situation and to

petition for better education for nurses, higher standards of nursing service, and better

pay (Lynaugh, 1992).

Up until World War II, nursing leaders had endeavored to improve nursing

education within impoverished hospital-based training programs while also ensuring

that the largely student work force provided safe nursing care (Lynaugh, 1992). The

acute nursing shortage that resulted from the war emergency served to expedite

government involvement in changing the patterns of nursing education. The Bolton


Act of 1943 established the Cadet Nurse Corps, the first federally subsidized nursing

program for students and schools. The students received tuition and a stipend in

exchange for a commitment to engage in military or civilian nursing for the duration

of the war. It fostered several changes within nursing education in that it established

minimum educational standards and barred discrimination on the basis of race and

marital status. Nursing schools were forced to revise their curricula as a result of

being required to reduce their programs from 36 months to 30 months (Kelly, 1987).

Meanwhile, nursing students were becoming less plentiful as accrediting agencies

placed restrictions on the use of student labor and as operating costs of hospital

schools increased. Both of these factors further exacerbated the nursing shortage

(Lynaugh, 1992).

Two other major changes that occurred in response to the acute wartime

nursing shortage have had long-term effects. First was the training of aides to assist

with basic nursing tasks. And second, the national nursing shortage led to the

recruitment of inactive nurses back into the practice setting. Prior to World War II,

nurses who had married or were unable to work full-time were not considered to be

acceptable employees. The continuation of a nursing shortage after the war facilitated

the ongoing acceptance of nurses who were married or who worked part-time and of

unlicensed assistive personnel in the hospital setting (Kelly, 1987).

Government-sponsored programs had an impact on nursing through

subsidized training programs for student nurses and for nurses’ aides. The nursing

shortage and the addition of unlicensed nursing personnel to the staff mix required


nursing administrators to develop a new model for the delivery of nursing care in the

hospital setting.

Functional Nursing Care Delivery Model

In an environment where there was an ever-increasing demand for nurses, it

became imperative to adapt the predominant nursing care delivery model from total

patient care to a functional nursing model. The composition of nursing staffs changed

from being primarily student and registered nurses to staffing patterns that were likely

to include nurses, licensed practical nurses, and unlicensed assistive personnel.

The focus of the functional method of nursing care delivery (also called task

nursing) is to carry out physician orders and to provide physical care through the

completion of tasks and procedures. Thus, staff assignments are decided according to

the job descriptions of each of the nursing staff and the amount and type of work that

needs to be completed. The nurse’s assignment might or might not take into

consideration the capabilities of the nurse or the condition/needs of the patient. In

staffs that include multiple levels of care providers, including unlicensed assistive

personnel, the least experienced staff is assigned most of the routine care (Kron &

Gray, 1987).

The greatest advantage to functional nursing is that each staff member

becomes very proficient at performing their regularly assigned tasks (Sullivan &

Decker, 1997). It is administratively efficient, highly regimented, with discrete roles,

and the coordination of staff activities, according to staff job descriptions, requires

minimal time. It enables patient care to be given with a minimal number of registered


nurses and is often used in times of acute nursing shortage (Barnum & Mallard, 1989;

Marquis & Huston, 1996).

The greatest disadvantage to functional nursing is the fragmentation of care.

The emphasis is on the work to be done. The head nurse is responsible for

coordination of care and patient outcomes. Quality may be compromised because

each staff member is focused on assigned tasks and often only the head nurse knows

the overall plan of care. There is no coordination of numerous tasks or with patient

needs unless the head nurse makes an effort to do so (Kron & Gray, 1987).

Although a nurse-patient relationship may develop between a nurse and

patient, it occurs by chance rather than by design. Nursing care is usually task-

centered rather than patient-centered, the patient is not viewed from a holistic

perspective, and there is inconsistent continuity of care. When staff members are

assigned to unfamiliar tasks, they are less efficient and less effective because they

seldom need to demonstrate proficiency in a broad range of skills (Sullivan & Decker,

1997). When staffing is adequate, both nurses and patients express more satisfaction

with total patient care than with the functional nursing method of care delivery (Kron

& Gray, 1987).

Summary

World War II increased the demand for nurses and caused a severe nursing

shortage in hospitals. The government, the Office of Civilian Defense, and the

American Red Cross began to train aides to assist with patient care. The expanded

ranks of semiprofessionals and assistive personnel and the recruitment of inactive


nurses who were married or who could not work full-time also expanded the nursing

work force. The nursing shortage persisted post-war because of government support

for the building and/or renovation of hospitals and limitations by accrediting agencies

on the staffing of hospitals by nursing students.

The development of functional nursing enabled the rapid transition of nursing

staff to include multiple levels of professional, semiprofessional, and unlicensed

nursing personnel. It differs from total nursing in that the focus is on completion of

tasks rather than on meeting all of the patient’s nursing care needs. Also, the tasks are

completed by a variety of nursing staff members according to role rather than by one

care provider per shift. The nurse-patient relationship is less of a priority in

functional nursing because each patient is viewed from the perspective of a list of

tasks that need to be completed.

One similarity between functional nursing and total nursing care is that there

is little focus on continuity of care. The two care delivery models differ in that

coordination of patient needs and a holistic approach to care is more likely to occur

with the total nursing model of care both within and across shifts. In functional

nursing, coordination activities are focused across types of personnel and types of

tasks.

Team Nursing (Mid 1940s to the Late 1960s)


In the aftermath of World War II, the expanded role of nurses, along with new

technologies, new medicines, and new equipment facilitated the on-going


development of nursing as a profession (Vogt et al., 1983). After the war, the

challenge for nursing leaders was to create an independent educational system and a

safe care delivery system that was mainly staffed by paid caregivers, many of whom

were nonprofessionals (Lynaugh, 1992).

In the aftermath of any war there is usually a shortage of nurses, but after

World War II the shortage occurred for different reasons. Although the number of

nurses was higher than ever, the population to be served had increased, as had the

number of hospitals and the demand for expanded health services. There were more

insurance plans available that paid for hospitalization, new technologies kept patients

alive longer, and there was an increase of in-hospital deliveries because of the

postwar baby boom. Five out of six military nurses chose not to return to civilian

nursing.

Civilian nurses had increased practice opportunities outside of the inpatient

setting as the demand for nursing services expanded in other areas of health care.

Although nurses with advanced skills were desperately needed, civilian hospitals

continued to experience an acute nursing shortage because of poor working conditions

and poor pay. Hospital nurses were routinely scheduled for split shifts, worked with

minimal staffing, and tolerated rigid discipline. Wages were kept at a minimum rate

and nurses made less for a 48-hour week than did typists or seamstresses (Kelly,

1987).

Practical nursing, aided by funding from federal education acts and with few

educational requirements, also proliferated during this era. In 1947 there were only


36 schools for training practical nurses but by 1954 the number had expanded to 296.

Despite major educational inconsistencies, the role of practical nurses expanded

rapidly to adopt those activities that registered nurses did not have the time to do. By

1952, 56% of nursing personnel were nonprofessional staff, and nurses became

concerned that they would be replaced by minimally trained staff (Kelly, 1987).

The government’s continuing efforts to expand the nursing workforce

provided the impetus for major changes within nursing education and nursing

practice. Nursing leaders faced multiple challenges as new opportunities became

available.


During the same period of time, nursing education was also going through a

major period of transition. Hospital schools of nursing often were criticized for the

poor educational quality of the teachers and of the training programs. However,

because students often provided about two-thirds of the nursing care delivered to

hospital patients, hospitals remained dependent on the nursing programs to provide

nursing staff (Kelly, 1987).

In 1948, Esther Brown, a social anthropologist who had conducted a study on

the quality of prewar hospital nursing programs, published results indicating that

hospital nursing programs were inadequate to prepare the level of professional nurses

who would be required to plan and supervise patient care. She maintained that the

primary function of many of the hospital-based diploma schools was to provide an

ongoing supply of staff for their hospitals. Brown recommended that nursing


education should occur within college curriculums, wherein nurses would have

increased exposure to the advances occurring within the medical and social sciences.

The study provided solid data about the importance of making nursing education

independent of hospitals (Vogt et al., 1983).

In 1950, nurse educator Mildred Montag, in her doctoral research at Teachers

College in New York, proposed a strategy that had a major influence in changing

nursing education. She recommended development of an associate degree nursing

educational program that could be taught in the rapidly expanding system of

community colleges and which would replace diploma nursing programs. Montag

and others conceptualized a two-tiered nursing system wherein (a) baccalaureate

prepared nurses would be responsible for patient care and would supervise the work

and (b) “technical” associate degree nurses would provide the care. However, the

demand for nurses was so great that both hospitals and state boards of nursing made

little differentiation between the graduates of baccalaureate, associate degree, or

diploma programs. Regardless of educational preparation, all nurses received the

same registration, nursing assignments, promotion opportunities, and pay (Kelly,

1987; Lynaugh, 1992).

Federal funding of nursing education also had a major influence on the

development of an independent educational system for nurses. Nurses exiting the

military were able to use the GI bill to extend their college education. The advent of

community college nursing programs increased the ability of many middle and

working class individuals to enter nursing. In addition, the federal Nurse Training


Acts of the 1960s increased the access of many nurses to undergraduate and graduate

levels of education. The infusion of these federal monies into colleges and

universities facilitated the ability of many nursing programs to move into the

mainstream of higher education (Lynaugh, 1992).

Nurse leaders began to define the conceptual domain of nursing and to form

the nucleus for the evolution of theories of nursing, based upon their educational

backgrounds, the philosophical underpinnings of their times, and the paradigms of

other relevant disciplines. In 1952, the journal Nursing Research was created to

report on the scientific investigations occurring within nursing (Meleis, 1991).

As college-based nursing programs developed, the focus on the “how to”

practice of nursing was replaced by a focus on what nursing curricula should be

taught, the best way to teach the information, and the functional roles of nurses.

Nurse educators, trying to develop curricula geared towards preparing nurses for

different educational levels, began to ask questions about whether nursing was a part

of medicine or one of the other biological, natural, or physical sciences or whether it

was truly a discrete discipline in its own right (Meleis, 1991).

Columbia University’s Teachers College

Columbia University’s Teachers College was one of the graduate nursing

programs that began to teach educational and administration theories during the

1950s. Early nursing theories were the products of broad intellectual endeavors by

nursing theorists to define the fundamental tasks of nursing. Several of Columbia’s

early nursing graduates, such as Peplau, Henderson, Hall, Weidenbach, Abdellah,


King, and Rogers, attempted to explain what nursing is and what it is that nurses do.

The emergence of these theories was strongly influenced by several factors (Meleis,

1991).

First, nursing leaders found that it was a challenge to adequately describe the

essence of nursing and/or to analyze nursing problems through the paradigms of any

one discipline. Second, nursing theorists were influenced by the theoretical ideas of

the time, such as the debate about whether nursing was part of a biological, natural, or

physical science, or simply a part of medicine, as they searched for conceptual

coherence within nursing. And third, the nurse theorists were influenced by their

educational and experiential backgrounds. The theories that emanated from nurse

leaders during this period of time have had a profound influence upon the

development of subsequent nursing theory and research (Meleis, 1991).

Meleis (1991) credited the early nursing theorists such as Peplau, Henderson,

and Orem from Columbia University’s Teachers College with developing the “needs

deficit school of thought”. In trying to answer the question of what do nurses do, they

conceptualized the functions of nurses in relation to the needs of patients. The

concept of patient needs was strongly influenced by Maslow’s hierarchy of needs, and

Erickson’s stages of development, rather than by the traditional medical model.

Hildegard Peplau was the first nursing theorist to articulate a theory of nursing

(Meleis, 1991). The centrality of the nurse-patient relationship to nursing practice

was strongly influenced by Hildegard Peplau's (1952) inductive theoretical model of

nursing as a dynamic interpersonal process. Development of her theory was strongly


influenced by theorists in the social sciences, such as George Herbert Mead and Harry

Stack Sullivan (Schmitt, 1983). Peplau is also considered to be the first nursing

interactional theorist because she delineated the phases of nurse-patient relationships

(orientation, identification, exploitation, and resolution) and the nursing roles that

emerge through the process of interpersonal communication.

In her book, Interpersonal Relationships in Nursing (1952), Peplau described

nursing as a significant, therapeutic process, as a function, and as an educative,

maturing instrument (Belcher & Fish, 1985; Peplau, 1952). She believed the primary

responsibility and goal of the nurse is to facilitate promotion of the patient’s physical,

emotional, and social well being. The patient expresses human needs and the nurse

utilizes the therapeutic, nurse-patient relationship to foster development and

improvement of the environment so that the patient’s energy is utilized for health-

promoting activities (Peplau, 1952).

Peplau’s interpersonal concept of nursing established a foundation for nurses

by defining the multiple roles that a nurse may assume to assist the patient through the

phases of the nurse-patient relationship. Coordination of care activities were not

addressed in the theory.

Yale University School of Nursing

In the late 1950s and early 1960s, the Yale University School of Nursing

became known as a center for the development of interactional nursing theories.

Several graduates of Columbia Teachers College, for example Orlando, Henderson,

and Weidenbach, became faculty members at the Yale University School of Nursing


and were influential in developing theories to describe how nurses do what they do.

These nursing leaders conceptualized nursing as an interaction process with an

emphasis on the development of the nurse-patient relationship (Meleis, 1991).

By the early 1950's, the nurse-patient relationship was becoming increasingly

recognized as a central feature of nursing practice that should be valued in its own

right. Nurses began to view nurse-patient interactions as not only contributing to

patients' physical health, but also to their mental health, by affecting their sense of

adequacy and/or well-being (Orlando, 1961; Peplau, 1952; Ramos, 1992).

According to Meleis (1991), multiple social forces facilitated the development

of the interactional focus of the faculty. Federal grant monies were available to

develop graduate level education and to develop integrated educational curricula. In

addition, the environment was ideal, with several faculty members who had been

influenced by Peplau and who had shared educational and clinical backgrounds, with

which to articulate the mission and goals of nursing.

Ida Jean Orlando published The Dynamic Nurse-Patient Relationship (1961)

in an effort to provide nursing students with a theory of effective nursing practice that

would facilitate the development of a professional nurse’s role and identity. Her

nursing process theory is centered on the dynamic interactions that occur between the

patient and the nurse and focuses on providing patient care that will sustain the patient

in the immediate illness situation.

The deliberative nursing process assists the nurse to understand the unique

needs of the patient and assists the patient to relate to and understand the nurse. It is


the intervening variable that differentiates between a nurse-patient relationship and a

social interpersonal relationship and is what defines nursing as a profession (Orlando,

1961; Schmieding, 1993; Schmitt, 1983). Orlando’s deliberative nursing process

guides the nurse to systematically assess and respond to patient needs within a

professional context. The theory gives additional structure to the process described in

Peplau’s orientation phase. The nurse’s unique perceptions will facilitate nurse-

patient interactions that are patient-centered and based on patient needs (Orlando,

1961; Schmieding, 1993).

Use of the deliberative nursing process assists the nurse to efficiently and

effectively develop a nurse-patient relationship wherein the nurse is able to

understand the unique needs of the patient and to evaluate the effectiveness of nursing

actions. Since the goal of the patient is to relieve or diminish feelings of distress, the

patient will respond to a relationship wherein actions are explicit, and will be able and

willing to communicate verbally and/or non-verbally when a relationship has been

established (Orlando, 1961; Schmieding, 1993). Although coordination of care

activities are not addressed explicitly, the nurse is accountable for ensuring that

holistic nursing care is provided to the patient.

Team Nursing Care Delivery Model

In the aftermath of World War II, the shortage of nurses and the rapid

expansion of medical technology led the Commission on the Functions of Nursing to

re-evaluate pre-existing care delivery models. In 1948, they recommended a team

approach to nursing care delivery (Lynaugh, 1992, Reed, 1988; Sherman, 1990).


The philosophy of team nursing is based on the belief that, when professional

nurses coordinate the nursing care provided by nursing personnel of various skill

levels, the achieved patient outcomes will surpass anything that can be accomplished

by any individual team member. Team members include registered nurses (RNs),

licensed practical nurses (LPNs), nursing assistants and/or patient care technicians, all

of whom have varying levels of responsibility for patient care (Sherman, 1990).

In team nursing, staff members are assigned to teams and each team provides

total nursing care to the patients assigned to that team. Leadership for each team is

provided by a team leader, who is an experienced registered nurse responsible for

planning and supervising the provision of nursing care for patients cared for by team

members. The team leader has overall accountability for coordinating the nursing

care provided, while the team members are accountable for completing their assigned

tasks and for documenting the care delivered (Marquis & Huston, 1996; Sherman,

1990).

Team nursing is a useful structure for nurses, whether they have extensive or

limited clinical experience. The team leader’s experience and role-defined leadership

responsibility promote individualized help, support, and supervision of less

experienced staff. The inexperienced nurse is systematically provided with an

experienced nurse in the mentorship role. The patient also benefits from the team

leader’s coordination of care and oversight of less experienced staff by consistently

receiving holistic high quality care. Moreover, because tasks and responsibilities are

divided among the team members, the patient interacts more often with team


members (Reed, 1988). Other advantages include the potential to recruit assistive

personnel into nursing, the enhanced communication and cooperation that occurs

among team members as compared to functional nursing, and the shifting of decision-

making authority and responsibility to the operational rather than the unit

management level (Sherman, 1990).

Despite these benefits, team nursing has been criticized from a number of

perspectives. Some of the concerns were because the focus was on the method itself,

rather than on the outcomes of the process. Team nursing was often implemented

without any real change from the functional nursing care model. Appointment to the

team leader role might or might not be based on demonstrated competence,

educational level, orientation to leadership responsibilities, and exposure to role

modeling experiences (Sherman, 1990). Consequently, the benefit achieved when a

senior practitioner mentors and oversees care delivery to a group of patients is not

typically seen. Disadvantages also include (a) the time required to communicate

among team members, the impact of frequent changes in team leader or team member

assignment on continuity of care, (b) the potential for nursing staff to focus on task

completion rather than holistic care, and (c) the difficulty in developing nurse-patient

relationships when nurses are assigned to a large team of patients (Sherman, 1990).

Unfortunately, because of the increased demand for hospital beds and the protracted

shortage of professional nurses, team nursing has often looked most like an assembly

line type of functional nursing (Lynaugh, 1992). In addition, many registered nurses


have found that they are able to do very little direct patient care because they

primarily pass medications and/or complete paperwork (Kelly, 1987).

Summary

For a variety of reasons, the shortage of nurses continued after World War II.

Nursing made great strides as a profession. Nursing education, with the aid of federal

funding made important progress in developing an independent educational system

for nurses. Nursing educators began to define the conceptual domain of nursing.

Nursing educators at Columbia University’s Teachers College and the Yale

University School of Nursing were major contributors to the evolution of theories of

nursing. Their theories focused on the different roles that nurses assume at different

times, i.e., needs oriented and interaction oriented

The goal of the team nursing care delivery model is to provide increased

structure for providing total patient care, using teams of nursing staff at various skill

levels. Although team nursing is similar to total patient care in that both care delivery

models share a goal of providing total patient care, in team nursing total patient care

is accomplished by a team of nursing personnel with various skill levels rather than by

only the assigned nurse. In team nursing there tend to be less interactions between the

patient and any individual nurse because of the number of team members who are

involved in addressing the patient’s needs. Both team nursing and functional nursing

utilize a team of nursing personnel, but in team nursing the team leader coordinates

the team’s work and the team is held accountable for total patient care rather than

completion of assigned tasks.


Primary Nursing (Late 1960s through the 1970s)


In 1965, the federal government amended the Social Security Act to authorize

the creation of Medicare Part A and Part B (Title XVIII) and the Medicaid program

(Title XIX). Both programs are under the management of the Health Care Financing

Administration (HCFA). Medicare was developed as a nationwide health insurance

program to ensure health care access for the aged and certain disabled individuals

(Kelly & Joel, 1996; Woods, 1996). The Medicaid program was designed to provide

medical services to certain groups of low-income individuals. It is a federal-state

means-tested entitlement program, meaning that the federal government pays about

56% of benefit costs and the states pay the rest. Medicaid programs differ

substantially from state to state because each state, using federal guidelines,

determines its own eligibility criteria and coverage standards (Kelly & Joel, 1966).

The health care industry also began to feel an impact from the “consumer

revolution” as consumers asked questions about the quality, quantity, and cost of

health care services. Kelly and Joel (1996, p. 89) defined the consumer revolution as

“the concerted effort of the public in response to a lack of satisfaction with the

products and/or services of various groups.” Consumers’ groups found that by

organizing they gained power through money, numbers, and influence and could force

providers to be more responsive to their demands.

For example, activities of the women’s movement had an impact on both

politics and health care in the 1960s and 1970s. The National Organization for


Women (NOW) was organized in 1966 to support full equality for women in the

workplace and to end discrimination and prejudice against women. In 1971, the

National Women’s Political Caucus was founded to promote the entry of women into

politics at leadership levels so that they could ensure that women’s issues were

addressed. The women’s health movement emerged from a health consumer group

that organized to address women’s dissatisfaction with the way in which they received

health care from health care professionals and institutions. Their self-help movement

became known for its know-your-body literature and its facilitation of feminist health

centers (Kelly & Joel, 1996).

The efforts of consumer groups facilitated change primarily through media

campaigns, lobbying for legislation, legal suits, and boycotts. For instance, the

American Hospital Association’s Patient Bill of Rights in 1972 was the result of

concerted efforts of minority populations. The widespread attention given to patient

rights by consumer groups subsequently lead to the creation of a government

commission with a focus on medical malpractice. The commission’s 1973 report,

Malpractice, stated that violation of patients’ rights was the main cause for the sharp

increase in malpractice suits (Kelly & Joel, 1996).

Since 1966, Congress has passed multiple amendments in an attempt to

control the costs of the Medicare program (Kelly & Joel, 1966). Congress passed the

Health Maintenance Organization Act of 1973 as a way to encourage the development

of managed care. As long as the health care industry could continue to bill patients

and/or insurance companies on a fee-for-service basis, and were reimbursed without


any limitations, there was little financial incentive to provide cost-effective care.

However, when the prospective payment system began to place limitations on

reimbursement, the health care industry began to intensively explore ways to improve

the management of care. Managed care evolved as a systematic response to a

wasteful healthcare system, one in which both expensive technology and costs were

expanding rapidly (Kelly & Joel, 1996; Powell, 2000).

In the 1960s, hospital and nursing administrators began to cluster the sickest

patients by geographical location, i.e., intensive care units, in response to advancing

technology and increasingly invasive therapies. Expert nursing enabled these new

technologies to be deployed successfully, and they, in turn, required nurses to acquire

even more specialized skills. The expanded technology also raised the demand for an

increased ratio of professional nurses in relation to other levels of care providers

(Lynaugh, 1992).

The efforts of consumer groups to ensure access and standards for quality

health care influenced the federal government during the late 1960s and through the

1970s. The federal government’s creation of Medicaid, commission on malpractice,

and amendments to control health care costs all impacted directly upon the evolution

of nursing education and practice.


Nurses were impacted by consumer activism as both health care professionals

and as consumers. As health care professionals they were responsible for practicing

in an ethical manner and for being aware of the legal ramifications of their actions.


As consumers, they often were supportive of goals that would impact them personally

as well as improve the quality of health care for their patients. Because the majority

of nurses were women, nurses were often supportive of the goals of the women’s

movement to some degree. However, at times this was an uneasy alliance due to the

emphasis of the women’s movement towards nontraditional work and fields of study

for women. Nursing was often categorized as a traditional female role with

traditional feminine values, such as caring, as an innate component of practice.

Unfortunately, nursing was at times viewed stereotypically, and not as a profession

with multiple dimensions for practice and advancement (Kelly & Joel, 1996).

In the aftermath of World War II, there was a shift in the number of nurses

who received a college education. Nurses coming out of the service were able to use

the GI bill and in the 1960’s, nurses were able to use federal funding for nursing

education to receive baccalaureate, master’s degrees, and doctoral degrees in

increasing numbers. These educational programs produced more nurses with the

advanced practice skills necessary to care for medically complex individuals

(Lynaugh, 1992).

In the 1960s, the population of the United States was growing rapidly, with an

average increase of 1.3% per year. By the early 1970s, many institutions of higher

learning had over expanded in response to the “baby boomers”, and many college

graduates had difficulty finding jobs after graduation. Educational programs, such as

nursing, that could offer immediate jobs with a future, attracted second-degree

graduate students from other programs. In the 1970s population growth slowed to a


1% increase per year and student enrollments at many institutions of higher learning

began to taper off. Nursing programs began to develop marketing strategies with

appeal for working adults in the community (Kelly & Joel, 1996). The decline in

population growth, along with growth in the number of associate and baccalaureate

nursing programs, contributed to the decline of diploma nursing programs.

The American Nurses’ Association (1965) created a position paper that

defined nursing as care, cure, and coordination and indicated that the most significant

goal for nursing was the development of nursing theory. During the late 1960s and

early 1970s, nursing researchers were focused on theory development and

identification of the structural components of theory. The majority of theories that

were developed during this period of time were metatheories. The influence of

theorists, such as Peplau and Orlando, had helped to establish the importance of the

nurse-patient relationship. Theorists, such as Travelbee and King, continued to

develop theories that focused on utilizing the nurse-patient relationship to provide

nursing care that meets the needs of patients, based on the perspective of the patient

rather than the nurse (Meleis, 1991).

Travelbee published Interpersonal Aspects of Nursing (1971) in order to guide

nursing students and professional nurses on how to effectively develop a helping

human-to-human relationship with the hospitalized adult and with other individuals

who are affected by the patient and the illness. Travelbee defined nursing as “an

interpersonal process whereby the professional nurse practitioner assists an


individual, family, or community to prevent or cope with the experience of illness and

suffering and, if necessary, to find meaning in these experiences” (p. 7).

Travelbee’s (1971) theory is consistent with the theories of Peplau and

Orlando in that she viewed the nurse-patient relationship as consisting of a complex

process involving several phases that was instrumental in accomplishing the goal of

nursing. In addition, the nurse-patient relationship evolves through reciprocal sharing

of thoughts and feelings by the nurse and the patient.

Travelbee (1971) was concerned about the depersonalization that often occurs

between nurses and patients as mere categories, labels, and stereotypes and wanted to

return the focus of nurses to the “caring” function of the nurse. It is reasonable to

think that functional and team nursing care delivery models influenced her belief that

care was mechanical and impersonal. She advocated the human-to-human

relationship as the means to accomplish the goals of nursing. To Travelbee, the

primary goal of the nurse is to express caring through development of a helping

relationship. The increased emphasis on the importance of the nurse-patient

relationship by nursing theorists positively influenced the creation of a nursing care

delivery model that would emphasize the importance of nursing care being provided

by a professional nurse.

Primary Nursing Care Delivery Model

Primary nursing was developed and implemented by Marie Manthey at the

University of Minnesota Hospitals during the late 1960s. The goal of this model was

to return the nurse to the bedside and to minimize the fragmentation of care associated


with team nursing. In the model, the nurse is viewed as self-directing and

autonomous and having accountability for patient outcomes (Reed, 1988; Scott,

Sochalski, & Aiken, 1999).

The philosophy of primary nursing emphasizes the nurse-patient relationship,

which serves as the foundation for professional nursing practice. This relationship is

maximized when a primary nurse and a small number of associate nurses provide

continuous, individualized care to the patient. In the primary nursing model, each

patient is assigned to a registered nurse who assumes responsibility for the patient’s

nursing care on a 24-hour basis. This responsibility extends from time of admission

through to discharge from the hospital. The primary nurse collaborates with other

health team members, the patient and family to continually assess, plan, implement,

and evaluate the patient’s nursing care. When the primary nurse is unavailable to

provide care, associate nurses follow the plan of care developed by the primary nurse

(Marquis & Huston, 1996; Reed, 1988; Sullivan & Decker, 1997).

In the 1980’s, primary nursing was identified as an essential characteristic of

“Magnet Hospitals” – a group of hospitals known for their ability to recruit and retain

professional nursing staff during a time of nation-wide nursing shortage. In these

institutions, the primary nursing model was described as an ideal approach for

assuring that important components of professional practice, such as the development

of nurse-patient relationships, nurse autonomy, and collaborative nurse-physician

relationships, were in evidence. Even when primary nursing was modified by the use

of nonprofessional nursing personnel, the research at magnet hospitals showed that


the foundation of the nurse-patient relationship was an essential component of

practice (Scott et al., 1999).

Proponents of primary nursing believe the focus on nurse-patient relationships

benefit both the patient and the nurse. The patient receives individualized care as a

result of the increased continuity and coordination of care. And in response, the

patient feels more secure about and satisfied with nursing care. The nurse also is

satisfied by clear role expectations, increased autonomy, and increased accountability

associated with the role (Sullivan & Decker, 1997; Wright, 1987).

Despite repeated discussions about the benefits of primary nursing, few

studies have supported the superiority of primary nursing over team nursing.

Moreover, a number of organizational and behavioral requirements must be evident

for primary nursing to be effective. First, communication from the primary nurse to

patients, associate nurses, and health team members must be consistent, clear, and

inclusive. Second, the primary nurse must be adequately prepared to effectively

coordinate interdisciplinary patient care. Third, the associate nurses must be willing

to follow the directions of the primary nurse. Fourth, the concept of 24-hour

accountability is misleading because primary nurses are not legally responsible for

nursing care that is delivered outside their work hours (Marquis & Huston, 1996;

Sullivan & Decker, 1997).

Summary

The consumer revolution impacted the health care industry as consumers

began to raise questions/concerns about health care and seek a greater role in making


health care decisions. Congress responded to the public’s concerns about the quality

and cost of health care by making amendments to the Social Security Act and by

creating the prospective payment system.

Nursing education was focused upon the development of theories of nursing to

define the domain and scope of nursing practice. Several of the predominant

metatheorists, such as Peplau, Orlando, and Travelbee, developed theories that

stressed the importance of the nurse-patient relationship.

The primary nursing care delivery model was developed to enhance continuity

of care and to place professional nurses at the bedside who could deliver high-quality,

specialized nursing care. Primary nursing increased the accountability of the primary

nurse to develop, monitor, and update the effectiveness of a 24-hour a day care plan.

Primary nursing, like the other patient care delivery systems that had been developed,

was found to have both positive and negative aspects.

During this time period, health care costs continued to escalate, consumers

expressed more dissatisfaction with cost and quality, and the federal government was

exploring ways to exert more control over health care industry costs and quality.

Each of the traditional nursing care delivery models had significant advantages and

disadvantages associated with it. Health care organizations and nursing

administrators needed to explore new ways to deliver nursing care effectively and

efficiently to patients.


Practice Models Impacting on Nursing Care Delivery Systems (1980s)


Health care costs increased by 716% over a period of 15 years ($13.9 billion

in 1965 to $99.6 billion in 1980). The federal government, in conjunction with state

governments, was paying over 50% of health care costs, mostly through Medicare and

Medicaid programs (Smith, 1985). According to Kelly and Joel (1996), these rapidly

escalating costs were due to several factors: (a) new technologies being developed for

diagnosis and treatment; (b) consumer demands for access to the latest and best

treatment options; and (c) care providers attempting to protect themselves from

malpractice suits, often by ordering an excessive number of tests/procedures.

The federal government, and especially HCFA, was able to exert a major

influence upon health care in the United States because most health care facilities and

care providers were dependent on funding and/or reimbursement from the

government. For example, HCFA not only served as administrative agent for Blue

Cross-Blue Shield, along with many other commercial carriers and group practice

prepayment plans, but these insurance companies also tended to follow governmental

patterns of payment.

As the American public expressed increasing dissatisfaction with the cost and

quality of health care and as concern mounted that Medicare funds would run out,

Congress enacted a number of Medicare and Medicaid amendments in an attempt to

control rapidly rising health care costs. The Tax Equity and Fiscal Responsibility Act

of 1982 was enacted to facilitate development of a Medicare prospective payment


system and other cost-cutting mechanisms for hospitals, skilled nursing facilities, and

some providers. This led to the Social Security Amendments of 1983, often referred

to as the DRG law, which established a prospective payment system to determine

preadmission diagnosis billing amounts for almost all American hospitals that were

reimbursed by Medicare. It also established peer review organizations and included

reimbursement for a variety of providers who had previously been excluded from the

program (Kelly & Joel, 1996).

Under the Medicare prospective payment system, 23 major diagnostic

categories (MDCs) were created to classify disorders of the human body by system.

Within these MDCs, 467 subgroups, called Diagnostic Related Groups (DRGs),

further refined classification according to illness and treatment. The government

calculates the average length of stay, the average cost expected for each DRG, along

with a stipulated reimbursement rate for each DRG. Hospitals receive a

predetermined amount for each case based upon each patient’s principal diagnosis

(what caused the patient to be in the hospital), the presence or absence of

comorbidities and complications, and whether surgery occurred. Whether a hospital

makes a profit or needs to absorb the cost depends on the amount of resources (length

of stay and services) utilized in relation to the amount reimbursed for the DRG (Kelly

& Joel, 1996).

Managed care evolved as care providers, hospitals, and insurance companies

grappled with ways in which to provide the best values in health care, while trying to

control costs. Definitions of managed care have been ever-changing, nebulous, and


often have focused on the strategies and limitations used within individual managed

care structures. Powell (2000) described managed care as a “mutating and dynamic

force” that is economically driven. In its broadest sense, managed care is defined as a

system of health care delivery that uses a variety of organizational structures such as

health maintenance organizations (HMOs), preferred provider organizations (PPOs),

and traditional health plans to manage health care costs, quality, and access to care.

Common denominators across managed care systems include a variety of restrictive

measures such as a limited panel of contracted providers, prior authorization

requirements to control/limit access to providers and services, utilization

management, capitation, and DRG reimbursement (Kelly & Joel, 1996: Powell,

2000).

From a narrower perspective, Williams and Torrens (1993, p. 226) stated,

“Managed care is defined as a set of techniques used by or on behalf of purchasers of

healthcare to manage healthcare costs by influencing patient care decision-making

through case-by-case assessments of the appropriateness of care prior to its

provision.” Through various organizational structures, the organization assumes

responsibility for providing and coordinating a defined set of services to a given

population (Powell, 2000).

According to Etheredge (1989), managed care uses tools and systems to take

existing information and make it more available to clinicians for enhanced decision-

making. The clinician’s control over patient care is enhanced through standardization

by case types. Case types are identified and the interdisciplinary standards of care,


including expectations about length of stay, processes, outcomes, resources and costs,

are developed. Within each case type, patterns of variation emerge and resource

requirements are adjusted to meet anticipated daily and discharge outcomes.

Optimally, patients are segregated by case type, that is, admission to a specified area

is based on the presenting diagnosis, so that variations from the care plan can be

identified and addressed promptly.

Managed care has substantially changed the health care reimbursement

structure from fee-for-service to prospective payment systems. There are divergent

views as to whether managed care has been a positive or a negative influence on the

quality of health care. Some view it as an elaborate bureaucratic ploy to limit

resources, while others view it as a way to make health care accessible to a larger

segment of the population. However, there is consensus that managed care, with its

requirements and restrictions, has dramatically increased the complexity of the health

care environment (Powell, 2000).

The Medicare legislation also mandated that each state create peer review

organizations (PROs) to establish a structure for quality assurance related to the care

provided to Medicare patients. PROs must be private entities in a competitive market

and a certain percentage of PRO boards must be consumers. Medicare also

authorized direct reimbursement to several new categories of providers, such as (a)

certified registered nurse anesthetists (CRNAs) for anesthesia services, (b) nurse

practitioners (NPs) and clinical nurse specialists (CNSs), in collaboration with a

physician, for certification and recertification of the need for nursing home care, and


(c) NP/CNS in a federally qualified health center or in rural or medically underserved

areas (Kelly & Joel, 1996).

Medicaid has expanded in recent years. Within the state and federal levels of

government, there has been an ongoing debate about what components of the program

are required versus optional. In 1986, Medicaid was expanded to provide necessary

health care to certain low-income women and children who had not been covered

under the Aid to Families with Dependent Children (AFDC) program. This increased

Medicaid eligibility because it was now based on federal poverty levels that routinely

used higher income levels than the state poverty levels. Although more low-income

individuals became eligible for services, the amount and scope of services were

reduced due to escalating health care costs. Within federal regulations, states

continued to make choices as to how to utilize their resources. For instance, some

states, such as Oregon, decided to put more of their resources into primary and

preventive services and to limit other expensive services (Kelly & Joel, 1996).

Another attempt of the federal government to address concerns about the

quality and the cost of health care led to the development of the Agency for Health

Care Policy and Research (AHCPR) within the Public Health Service (a division of

the Department of Health and Human Services). The mission of the AHCPR

included (a) assessment of technology, (b) development of practice guidelines, and (c)

research on the quality and effectiveness of health care services. Through the Medical

Treatment Effectiveness Program (MedTEP), the agency had the responsibility of

evaluating and improving the effectiveness of health care practices on patient


outcomes. Since its inception, the agency has utilized expert panels that include

nursing representation to develop multiple professional consensus-based guidelines

for the management of specific disease conditions (Kelly & Joel, 1996).

Nursing was strongly influenced by the federally mandated development of a

prospective payment system, managed care, and consumer concerns about the quality

and cost of health care. Older nursing theories and care delivery models were

explored and adapted in order to respond to the changing health care environment.


Within nursing education, theories of nursing were incorporated into the

curricula of nursing programs and considered to be a core content area. Nursing

theories that had been developed at the Yale School of Nursing, such as Orlando’s

theory about the dynamic nurse-patient relationship, were reconsidered and had an

impact on theory development in the 1980s. These theories became the source for

identifying the domain concepts, that is, those concepts perceived to be central to

nursing. The nurse-patient relationship and caring were two of the domain concepts

that were re-examined during this period of time in terms of further clarification and

refinement (Meleis, 1991; Schmeiding, 1983). In the 1980s, much of the work on

nurse-patient relationships occurred within the proliferating nursing literature and

research on the concept of caring.

In an attempt to clarify the various definitions of caring and its main

characteristics, Morse, Solberg, Neander, Bottorff, and Johnson (1990) reviewed the

nursing literature and identified authors who either explicitly or implicitly defined


caring. They categorized the caring conceptualizations of 25 authors, not according to

the major focus of their theory, but rather on the basis from which their perspective

was derived. In the review, they identified five epistemological perspectives on the

nature of caring: caring as a human trait, caring as a moral imperative or ideal; caring

as an affect; caring as the nurse-patient interpersonal relationship; and, caring as a

therapeutic intervention.

Authors such as Leininger (1985) and Roach (1987), who conceptualized

caring as a human trait, viewed caring as an innate part of human nature. Although

all human beings have the potential to care, the expression of caring is not uniform,

but rather influenced by factors such as culture and past experiences. From this

perspective, the nurse’s natural caring ability is enhanced by professional educational

experiences and is the motivator of nursing actions (Morse et al., 1990).

Authors with the perspective of caring as a moral imperative viewed caring as

a fundamental value or ideal, which provides the basis for all nursing actions. For

instance, both Gadow (1985) and Watson (1985) defined caring as a commitment to

maintaining an individual’s dignity or integrity. However, Gadow pragmatically

viewed the nurse’s caring as being a realistic and attainable goal of nursing practice,

whereas Watson viewed caring as an unattainable ideal that motivates caring actions

within nurse-patient encounters (Morse, Bottorff, Neander & Solberg, 1991; Morse et

al., 1990).

According to Morse et al. (1990), authors with the perspective of caring as an

affect define caring as “extending from an emotional involvement with or an


empathetic feeling for the patient experience” (p.5). From this perspective, the nurse

is motivated to function altruistically, that is, without immediate gratification or

expectation of material reward.

Authors such as Knowlden (1991), Horner (1991), and Weiss (1988)

perceived caring in the nurse-patient interpersonal relationship to be the essence of

nursing. Caring is communicated through the feelings and the behaviors that occur

within the relationship. Indeed, caring is both defined and expressed through the

nurse-patient relationship (Morse et al., 1990). Caring is a mutual endeavor between

the nurse and the patient and both parties benefit from the reciprocal interaction. In

order for caring to occur, the nurse and patient must be able to express

communication, commitment, trust, and respect for each other (Morse et al., 1991).

Caring as a therapeutic intervention conceptualizes specific nursing

interventions or therapeutics as necessary conditions for caring actions. The

perspective is patient centered in that the patient must demonstrate needs and nursing

care is aimed at meeting patient needs. Theorists such as Swanson-Kauffman (1988)

and Orem (1985) stressed that nursing knowledge and skills are needed in order to be

able to carry out caring actions and to bring congruence between the patient’s

perception of need and the initiation of nursing actions (Morse et al., 1991).

Morse et al. (1990) also found that several authors examined the concept by

exploring the physiologic or psychological outcomes of care and caring. These

researchers primarily focused on quality assurance indicators of care, with the

majority of outcomes measured being physiologic in nature.


Although Morse et al. (1990) classified authors according to the primary

emphasis that they had given to caring, many authors viewed caring as a process that

encompasses more than one category. For instance, although Gadow (1985) viewed

caring as a moral imperative, she explicitly linked her ideas about caring to the

categories of interpersonal interaction and the patient’s subjective experience.

Although Swanson-Kauffman (1988) primarily described caring as a therapeutic

intervention, she implicitly linked to caring as an interpersonal intervention with the

patient (Morse et al., 1991).

The emphasis that nursing theorists placed on defining core concepts led to a

proliferation of caring literature and research that occurred during the 1980s. Those

authors, who viewed the nurse-patient relationship as caring or as an essential

component of the process, added to nursing knowledge about the importance of the

nurse-patient relationship in caring.

Nursing Care Delivery Models and Practice Models

According to Olivas, Del Togno-Armanasco, Erickson, and Harter (1989), the

DRG-based prospective payment system, along with its incentives, contingencies, and

constraints, led to more dramatic change within the health care industry over a 5-year

period than had been experienced within the previous three decades. Nursing leaders

were challenged to improve quality and minimize costs while dealing with current

and anticipated nursing shortages. Nurse executives explored a variety of strategies

for professional nurses that would produce both cost-effective accountability and

increase satisfaction. This resulted in a proliferation of case management programs


and alternative care delivery models, all with the goal of improving patient, caregiver,

and system outcomes.

According to Powell (2000), nursing leaders responded to these new health

care constraints as an opportunity to expand nursing practice and patient advocacy

roles. The development of case management enabled nursing to balance the

constraints and limitations that were imposed by managed care while ensuring that the

patient received caring, high quality nursing care.

From a historical perspective, case management was a reasonable evolution

and expansion for nursing, based upon the community-based nursing coordination

that had been done by public health nurses since the turn of the century (Lyon, 1993).

Following World War II, the concept “continuum of care” was used to describe the

long-term community-based nursing programs that emerged to provide care for

discharged psychiatric patients. When the Community Mental Health Center Act of

1963 led to deinstitutionalization, that is, discharge, of mentally ill individuals from

psychiatric facilities into the community, it became apparent that community services

were fragmented and patients frequently required readmission to acute psychiatric

facilities. By the early 1970s continuum of care services had evolved into “case

management” and began to be used for other populations who required long-term

coordination of services. The term first appeared in the social work literature and,

closely thereafter, in the nursing literature. In the early 1980’s, community-based

alternatives to institutional placement for the aged and other chronically ill

populations through case management were facilitated by the Omnibus Budget


Reconciliation Act, Medicare prospective reimbursement and federal demonstration

projects (American Nurses’ Association, 1988; Lyon, 1993).

Case management is a popular term that has been used to describe a wide

variety of programs and activities within both acute care hospitals and community

settings (Lyon, 1993). Many of the definitions found in the literature have tended to

confuse rather than to clarify the concept for a variety of reasons. The definitions of

case management depict either: (a) a specific model of case management; (b) the

process, that is, the role of a case manager; and/or (c) the overlapping functions of

managed care (Powell, 2000).

The definitions of Etheredge (1989), Kane (1988), and the American Nurses’

Association (1988) are complementary and each describes case management as a

process and by its goals. Etheredge (1989, p.2) defined case management as a

“system of patient care delivery that focuses on the achievement of outcomes within

effective time frames and with appropriate use of resources,” and added that it

“incorporates the principles of managed care as well as the principles of

accountability for outcomes that come from primary care.” Kane (1988, p. 161)

defined it as the “coordination of a specific group of services on behalf of a specific

group of people. Case management can also be defined by listing its component

processes. By widespread agreement, these processes include screening or case

finding; comprehensive multidimensional assessment; care planning; implementation

of the plan; monitoring; and reassessment.”


The American Nurses’ Association (1988) defined case management as a

process that is comprised of similar core components: health assessment, planning,

procurement, delivery and coordination of services, and monitoring to assure that

complex needs of the client are met. The framework for nursing case management

has evolved from a blending of the core components of case management with the

stages of the nursing process. Nurses traditionally have utilized the nurse-patient

relationship to assist patients to move towards promotion and/or restoration of health.

The ideal candidates for case management are patients/clients who require complex

and costly care. The nurse’s role as a patient advocate and as a coordinator of care

services becomes even more central within a case management process.

The goals of the case management process are to provide quality health care

along a continuum, decrease fragmentation of care across settings, contain costs, and

enhance the patient’s quality of life (American Nurses Association, 1988). Lyon

(1993) stated that case management provides a service delivery approach that has two

additional goals: to provide alternatives to institutionalization and to improve the

patient’s functional capacity. All of these goals are relevant and add quality to health

care, regardless of whether reimbursement is prospective payment or fee-for-service.

Because case management serves both patient-centered and system-centered purposes,

both the patient and the system may benefit directly from the process.

According to Etheredge (1989), the nurse’s role is the focus of change in the

development of a case management model. The nurse who functions as a case

manager assumes accountability for the case management outcomes of care for a


specific population. The patient population may be clustered by case-type, that is,

diagnosis or procedure, by geographical location, by physician, or by a specific

combination of clustering criteria. For example, the case manager may be responsible

for all patients of Dr. X who have a specific diagnosis.

The case manager can be selected from many disciplines within the health

team. However the majority have been chosen from nursing or social work. Until the

mid-1980s, social workers traditionally held the position of discharge planner. With

the advent of prospective payment and managed care, health care developed an

increased emphasis upon outcomes, including cost-effectiveness. The background

and training of nurses that provided them with the requisite knowledge of disease

processes and treatments, health maintenance, a theoretical background based in the

biological and social sciences and the humanities, and a long experience in

collaborating with physicians, placed them in a unique position to function as case

managers. In addition, within many settings, such as acute hospital care, the

predominance of the medical model increased the likelihood that nurses would be

chosen to function as case managers. However, regardless of whether a nurse or a

social worker is chosen as case manager, it is important to note that an

interdisciplinary team usually is crucially involved in all phases of case management

(American Nurses Association, 1988; Powell, 2000).

The tasks of a case manager vary according to the case management model

being used, the organizational setting (i.e., inpatient versus community), the specific

population being managed, and expectations of the practice. Case management


services may be continuous or episodic. However, despite all of these variations, the

nurse case manager needs to have certain skills and perform certain activities in order

to accomplish the core components of the case management process effectively

(American Nurses’ Association, 1988).

Within all types of case management, the case manager provides both

facilitating and gatekeeping functions for the patient being case managed. Facilitative

functions include assisting the patient/family to: (a) access and/or navigate the

complexities of the health care system, (b) make informed decisions based on needs,

preferences, and resources, and (c) receive personalized care. Gatekeeping functions

include assuring that the patient receives appropriate resources in a timely manner and

that care is cost-effective (American Nurses Association, 1988).

Multiple versions of case management models have proliferated within health

care. The three predominant types of case management programs are: (a) hospital-

based models, (b) community-based models, and (c) continuum of care models that

span hospital and community settings. The hospital-based programs provide case

management services primarily during the course of a hospitalization (Lyon, 1993).

The nursing case management program that was established at the New

England Medical Center in 1985 is a well-publicized example of a hospital-based

nursing case management program (American Nurses’ Association, 1988; Lyon,

1993; Zander, 1990). Their case management program modified their existing

primary nursing care delivery model, by adding managed care and case management

responsibilities to the nursing role (Lyons, 1993). In this model, selected nurses


functioned as a case manager for a designated group of patients, in addition to

providing primary nursing care to an assigned group of patients. Assignments varied

as to whether the nurse would or would not provide primary nursing care for the

patients being case managed.

The goals of the model were to develop a balanced emphasis on quality and

health care resources by: (a) establishing and achieving expected or standardized

outcomes for each patient; (b) facilitating discharges that were early or within

appropriate lengths of stay; (c) reducing or maintaining the appropriate use of

resources to meet expected patient outcomes; (d) facilitating continuity of patient care

through collaborative practice with diverse health care professionals; (e) enhancing

the professional development and job satisfaction of team members; and (f)

encouraging contributions of all care providers by the transfer of information from

expert to novice staff members about the expected patient outcomes (Drucker, 1994;

Zander, 1990). According to Zander (1990), these goals would be accomplished

through the use of interlocking components from nursing case management and

managed care.

The four components central to the New England Medical Center nursing case

management model were: clinical and financial accountability for patients’ entire

episodes of care, the use of a primary nurse as case manager, formal RN-physician

group practices, and increased patient/family participation in care. The nursing

components utilized six components of managed care: standard critical paths used in

conjunction with care plans, individualized critical paths, analysis of positive and


negative variance, timely case consultation, health team meetings, and variances that

are aggregated, analyzed, and addressed (Zander, 1990).

Nursing literature contains multiple articles clarifying the difference between

nursing care delivery models and practice programs, such as case management.

According to Lyon (1993), the objectives of nursing care delivery models within

hospital settings are to use the nursing process to provide nursing care during the

course of a patient’s hospitalization. Goals are short-term, and usually do not extend

beyond the period of hospitalization on a particular patient unit. The most

predominant nursing care delivery models continued to include variations of team

nursing, primary nursing, modified primary nursing, and managed care models.

Although components of case management became incorporated into many of the

nursing care delivery models, the focus of nursing care delivery models was the scope

of nursing interventions utilized in the provision of direct nursing care. For example,

the New England Medical Center nursing case management model has been described

as a second-generation primary nursing model that was developed to maintain quality

while controlling health care costs (Drucker, 1994).

Manthey (1991) developed the “Balanced Department Concept” to illustrate

how nursing care delivery and practice models determine the quality of patient care

that is provided by any nursing department. Nursing care delivery consists of a

dynamic balance that is maintained between routine resource management (the

denominator) and the structure, process, and content of practice (the numerator).

Routine resource management requires a stable foundation of operations and the


administrative technologies to adequately staff a nursing department. Once the

operational foundation is assured, four kinds of distinct, but related, strategic

decisions (i.e., philosophy of resource utilization by the chief nursing administrator,

choice of delivery system, practice expectations, and configuration and development

of the role of the registered nurse) are utilized to determine how nursing will be

practiced. In addition, models or programs that structure the role of the registered

nurse, such as case management and differentiated practice, have a direct impact upon

the role of the registered nurse and can impact the delivery system and practice

expectations (Manthey, 1991).

The “Differentiated Case Management Model” was developed at the Sioux

Valley Hospital (SVH), as part of the South Dakota Statewide Project in the late

1980s. The differentiated practice model was based upon concepts of case

management and differentiated practice. Distinct levels of nursing practice (i.e.,

nursing case manager and nursing case associate) were based on defined

competencies in the areas of provision of care, communication, and management of

care. The competencies were then incorporated into job descriptions (Koerner,

Bunkers, Nelson & Santema, 1989).

Although the competencies adhered closely to traditional baccalaureate degree

and associate degree roles, SVH also considered multiple other factors. On the pilot

units, the process of nurse assignment to case manager or case associate level roles

included: educational preparation, individual nurse abilities and initiative, experience


level, self-assessment, nurse manager assessment, and a mutual decision for

placement (Koerner et al., 1989).

The “Primary Practice Partners Model” was another model that impacted

nursing care delivery. According to Manthey (1989), the model was developed to

delineate the responsibilities of the professional nurse in accomplishing nursing care

activities, in partnership with a “nurse extender” who provides technical assistance to

the senior partner. The nurse extender works under the auspices of the nurse and the

nurse is responsible for the performance of the junior partner. The partnership is a

new organizational construct, in that the primary partners share the same schedule and

function within a defined relationship.

According to Tonges (1989a, 1989b) the “Professionally Advanced Care

Team (ProACT) Model” was also developed to delineate nursing roles and to

restructure ancillary services at the service level in such a way as to provide

maximum support to the patient and the nurse. The two distinct roles developed for

registered nurses were the clinical care manager and the primary nurse. The model

also laid out a structure to extend the efforts of the primary nurse through the use of

licensed practical nurses and unlicensed nursing personnel to work together as a team.

Summary

Congress responded to the rapid escalation of health care costs by establishing

the Medicare prospective payment system. Managed care evolved as a system of

organizational structures created for the purpose of controlling costs, while

maintaining quality and access to care. Nursing education incorporated nursing


theory into the curricula of nursing programs and endeavored to define those core

concepts that were central to professional nursing practice. Several new practice

models evolved within nursing practice. Models such as case management and

differentiated practice were attempts to augment nursing roles in such a way as to

increase accountability and quality of patient care, while controlling resource

utilization and costs. Other models, such as the Primary Practice Partners model and

the ProACT model, also increased the accountability of nurses but were mainly

focused on delineating specific nursing roles when working in conjunction with

licensed practical nurses.

The specialized case manager’s role was an extension of the primary nursing

model in that it enhanced continuity of care and the case manager was accountable for

a 24-hour a day plan of care. The role of the case manager was also influenced by the

“interactional theorists” and by Travelbee’s focus on humanizing the nurse-patient

relationship. Case management emphasized the need for the case manager’s

relationship with the patient as the case manager functioned as a stable health team

member ensuring coordination of many aspects of the patient’s care.

Continuity of Care and Interdisciplinary Practice (1990s)


Changes in Population Demographics

The United States population in the 1990s reflected the considerable change

that had occurred over the several previous decades in terms of aging, ethnic

diversity, and family demographics. The graying of America has had a significant


affect on public policy and on health care. According to 1990 US Bureau of the

Census data, the United States population totaled 249.9 million people and 12.6% of

those individuals were 65 years or older. The percentage of individuals 85 or more

years old was 1.2%, making them the fastest growing category of the US population

(Kelly & Joel, 1996).

A smaller percentage of the population was Caucasian than in earlier times

and the population was less homogenous in traditions and values. The majority of

new immigrants were mainly Hispanic, from the Americas, and Asian. Because the

majority of new immigrants spoke one language, Spanish, ethnic neighborhoods

developed. The growth of communication services that enabled ongoing

communication in Spanish slowed the assimilation of ethnic neighborhoods into the

broader community. This differed from previous immigrants who came from a large

number of countries and had an incentive to learn English in order to use media

resources and to meld into a multiethnic society (Kelly & Joel, 1996).

The population has become increasingly urbanized, with 79% of the

population living in urban areas in 1990, in comparison to 63% in 1960 and 78% in

1980. In 1992 the average American household contained 2.62 people, the smallest

number in census history. Family structure has become less traditional, with a

decrease in the number of people in a household due to factors such as an increase in

the number of one-parent families. An increased number of women are working

outside of the home; in households containing children and two parents, 47% of

women are employed (Kelly & Joel, 1996).


Kelly and Joel (1996) point out that heart disease, cancer, stroke, personal

injury, and chronic obstructive pulmonary disease are still the major causes of death

in the United States. Personal lifestyle and social environment factors, such as

tobacco use, diet and activity patterns, substance abuse, risky sexual behavior, motor

vehicle accidents, and toxic agents, contribute significantly to our country’s death

rates. Modification of these risk factors can enable many individuals to lead a long

and productive life. The incidence of chronic disease and disability has increased due

to both lifestyle choices and increased medical technology and scientific advances.

Disability from chronic disease increased from 9.4 % of the population in 1987 to

10.6% by 1993.

Reports about gains made in United States’ health indicators can be

misleading. Aggregate data about minority populations actually show a growing

disparity for several health indicators, such as higher mortality rates for black infants

than for white infants. Poverty is a feminine issue because it remains

disproportionally high for women. The number of single mothers has increased from

5.5 million to 7.7 million in the last decade and women maintain almost 90% of one-

parent families. In 1991, statistics indicated that women without spouses maintained

54% of all families living at poverty levels (Kelly & Joel, 1996).

Government Interventions

The government has continued to accept a major financial commitment in

relation to health care. As a political expedient, the demands and/or needs of

consumers contribute to the ongoing shaping and reshaping of the Medicare and


Medicaid programs. The federal government has been able to impose federal criteria

that ensure equity for all elderly recipients because Medicare is federally funded.

Healthcare institutions must periodically demonstrate adherence to Joint Commission

on the Accreditation of Healthcare Organizations (JCAHO) standards in order to be

eligible for Medicare reimbursement. This provides a powerful incentive for

hospitals and other healthcare institutions to maintain high levels of quality. Because

reimbursement rates have remained within reason, providers have accepted the

established rate as payment-in-full for the poor elderly. In addition, if the poor

elderly exhaust their Medicare benefits, Medicaid subsidizes their health care costs

(Kelly & Joel, 1996; Kobs, 1999).

Medicaid has not fared as well. The prevailing strategy for controlling

escalating costs has been to offer a wide range of services, while setting

reimbursement rates so low for care providers that many have rejected/limited caring

for Medicaid patients. This has resulted in increased emergency room utilization for

primary care by the poor. Hospitals have been unable to limit inappropriate

utilization or they will not qualify for state or federal reimbursement of services or

programs (Kelly & Joel, 1996).

In an effort to cap escalating costs, both Medicare and Medicaid continue to

move towards managed care. A “Medicare Select” Program was piloted in 15 states,

wherein Medicare recipients who chose a managed care option were able to obtain

discounted “Medigap” coverage. Before a full evaluation was completed, the

program was expanded to all states for an extended period of time. By 1995,


managed care programs provided coverage for 10% of all Medicaid recipients (Kelly

& Joel, 1996).

In 1989, the federal government enacted legislation that allowed for coverage

of Medicaid patients by family and pediatric nurse practitioners. Beginning in July

1990, states were required to cover the services of these types of nurse practitioners,

as long as they were practicing within the scope of state law (Kelly & Joel, 1996).

Consumer Activism

As technology has increased, there has been concern that technological

advances would lead to depersonalized health care. In other words, as “high-tech”

machines are able to do increasingly sophisticated monitoring and procedures, the

importance of human interactions may be viewed as having less value. In a response

to this concern, “high-touch” care delivery systems, such as hospice care, primary

nursing, and neighborhood clinics have been developed to ensure a more humane

environment. The use of computers has proved to be beneficial in making highly

technical environments more humanistic by increasing the ability to share information

and to facilitate contact between people (Kelly & Joel, 1996).

Consumer concerns about depersonalization of health care have increased

consumer activism. For example, in 1991 the federal government passed the Patient

Self-Determination Act in order to ensure that patients receive information about their

health care choices and have the right to specify their health care preferences

(Jacobson, 2000).


The nursing community has responded to consumer concerns by continuing its

long history of supporting public policy that enhances the effectiveness of consumer

activists. The women’s movement especially has served as a major catalyst in

increasing awareness of women’s issues such as sex discrimination and women’s

rights. In 1991 a partnership called the “Community- Based Health Care Project” was

created by the American Nurses Association and the National Consumers League and

funded by the Kellogg Foundation. The project supported the development of

community based nurse-consumer coalitions, which worked to ensure that local needs

were addressed when public policy was developed or changed. Also, the American

Nurses Association and the National League for Nursing developed a supportive

directive, entitled Nursing’s Agenda for Health Care Reform, for public policy reform

(Kelly & Joel, 1996).

Change within Health Care Organizations

According to Nagaike (1997), health care costs accounted for 14% of gross

domestic product by 1992, in comparison to 9% in 1980. This occurred in

conjunction with new regulations related to prospective payment and the Commission

on Accreditation of Healthcare Organizations (JCAHO) and rising operating and

personnel costs.

Many health care organizations used restructuring or reengineering

interventions as the dominant strategy to maintain and improve the quality of health

care services while reducing costs (Sovie & Jawad, 2001). Hospitals were the

financial centerpiece of restructuring activities because they account for the largest


portion of health care spending in most industrialized countries (Sochalski, Aiken, &

Fagin, 1997).

The structure of an organization is characterized by its level of complexity,

formalization of rules and procedures, and centralization of decision-making

authority. The following structural changes were implemented widely by many

health care organizations: (a) development into corporate health systems that are

multilevel and multilateral; (b) management hierarchies that became horizontal or flat

rather than the traditional pyramid-shaped hierarchy; (c) shift to a matrix or product

type structure from a traditional functional structure; (d) shift to managed care,

whereby the delivery of care is determined by someone other than the care provider;

and (e) patient-focused clinical management of care. Many of the organizational

changes were implemented without empirical evidence that outcomes would be more

effective or efficient (Crowell, 1996: Nagaike, 1997; Pence, 1997; Sochalski et al.,

1997).

According to the quality management model of Avedis Donabedian, structure,

process, and outcomes influence quality. Structure is defined as the stable aspects of

the environment, such as numbers and types of staff and their competence,

administrative policies, facilities, and equipment. Donabedian considers the structure

of an organization as the most important means of maintaining and improving quality

of care. Structure impacts the process of care delivery and both structure and process

have an effect upon patient outcomes (Sovie & Jawad, 2001). Changes in

organizational context due to restructuring altered fundamental health care processes,


such as provider-patient relations and clinical decision-making, and had an

increasingly powerful impact upon patient outcomes (Aiken, Sochalski & Lake,

1997).

Restructuring and reengineering changes within health care organizations are

often perceived as reactive strategies to improve quality, while controlling costs.

However, these strategies can also be considered proactive actions implemented by

complex adaptive systems to constructively respond to changing requirements.

Changing Theory of Organizations as a Context for Health Care, Using the Model of

Complex Adaptive Systems as an Example

In 1998, the Institute of Medicine formed the Committee on the Quality of

Health Care in America for the purpose of developing strategies to improve the

quality of health care within the United States. The first of several reports, To Err is

Human: Building a Safer Health Care System, was published in 2000 and focused

primarily on patient safety (Kohn, Corrigan & Donaldson, 2000). The Committee

developed principles and strategies for redesign of health care, based upon the

framework of complex adaptive systems and its application within “learning”

organizations. The recommendations of the Committee have impacted the redesign

of systems, performance improvement efforts, and provided a template for the

establishment of national priorities within the health care community (Institute of

Medicine, 2001).

Traditional organizational principles have been found to be incomplete

because of their inability to address the unstable conditions and paradoxes that occur


within any human organization (Peirce, 2000). The science (or theory) of complexity

was developed to provide an explanatory framework for human nonlinear feedback

networks, especially complex adaptive systems. The comprehensive theory provides

a mechanism for the organization of existing beliefs about human systems into a

markedly different theory of organizational evolution (Plesk, 2001; Stacey, 1996).

It is not surprising that leaders in health systems management have become

increasingly interested in exploring the theoretical model of complex adaptive

systems (CAS) as a potential mechanism to redesign health care in the 21st century.

The United States health care system can be viewed as a complex adaptive system

that consists of many components, such as hospitals, clinics, pharmacies, and

laboratories. These components, which function both independently and

interdependently with each other, share the common goal of maintaining and

improving health (Arndt & Bigelow, 2000; Plesk, 2001).

In reality, health care organizations, and the individuals who function within

them, respond to internal and external stimuli with a wide variety of actions or

behaviors that are not always predictable. These actions are interconnected in ways

that change the context for other agents within the organization and the system.

Ultimately, the success of an organization is linked to its ability to constructively

respond to contradictions within its environment. The organizational theory of CAS

appears to provide a way in which to understand and respond to rapid paradoxical

changes within the health care system. When parts of the system interact with other

parts of the system in ways that constitute learning, they form a coevolving


suprasystem that has the potential to “learn its way into the future” (Peirce, 2000;

Stacey, 1996).

The organization confronted with new stimuli is functioning at the “edge of

chaos”, which is the term used to describe the area of bounded instability that is found

during the transition between zones of order and disorder within a complex adaptive

system. The goal of the organization is to create a “zone of complexity” or a “space

for novelty”, wherein agents within the system are able to deal with paradoxes within

the system and have the ability to respond with endless variety and creativity. The

links between cause and effect disappear when systems function at the edge of chaos

because neither the changes in schemata nor their outcomes can be known or

predicted. There is an acceptance of the lack of established organizational control,

based upon the premise that redundancy and cooperation among agents who are

coevolving will result in an inherent order that results in true empowerment and

emergent strategies of self-organization (Plesk, 2001; Stacey, 1996).

Plesk (2001) stresses that studies of complex adaptive systems identify a

number of elements that can be beneficial to health care redesign. These include: (a)

self-organizing and adaptable elements within the system; (b) simple rules; (c)

nonlinearity between actions and outcomes; (d) continual creativity; and (e) inability

to make accurate, detailed predictions. The Institute of Medicine’s Committee on

Quality of Health Care in America (2001) has incorporated these elements into their

recommendations for the redesign of health care systems.


Arndt and Bigelow (2000) expressed concerns that it is imperative that the

potential of chaos theory and complexity theory not be wasted if they are to be

maximally effective in guiding the restructuring of American health care. Based upon

past experiences with new ideas, they caution that the language used in the theories

should not become incorporated into practice until a substantive change in conduct

has occurred and that the theories not be prematurely translated into normative

prescriptions for health care managers.


Nurse leaders in practice and education were influenced by population

changes, government interventions, consumer activism, reengineering and

restructuring occurring within health care organizations, and the Institute of

Medicine’s recommendations for redesign of the health care system. They

constructively adapted to changing requirements through an emphasis on quality

outcomes, expansion of the nurse role in case management, and the nurse’s role as an

active member of the interdisciplinary team.

According to Shoultz, Hatcher, and Hurrell (1992), the IOM report stimulated

nurse leaders to propose that the nursing profession develop more direct roles in

meeting the public’s health service needs. They proposed that a paradigm shift was

needed within nursing education so that primary health care concepts are integrated

into nursing curricula, along with an emphasis on incorporating interdisciplinary

collaboration and communication into practice and research.


The PEW Health Care Commission identified challenges for the nursing

profession related to the restructuring of health care and recommended that nurse

educators revise and revamp educational programs to include broader approaches to

patient care. These changes include population-based health care, interdisciplinary

approaches to education, and integrated approaches to managing patient care needs

(Korniewicz & Palmer, 1997).

Outcomes Research and Practice

According to Lamb (1997), the health care industry as a whole has become

increasingly interested in system and network outcomes, because of changes in

organizational structures from reengineering, mergers, and new forms of

reimbursement, such as capitation. The target of “seamless integration” has led to

questions about how to provide the “right” service, at the “right” time, in the “right”

place, and at the “right” cost. Health care organizations are trying to identify the

clinical and financial parameters that will indicate whether change within a system or

network is successful and to predict trends in productivity. Health care administrators

have great financial incentives to evaluate nursing innovations, such as case

management, primary care, and chronic illness care, in terms of their effect on

network outcomes across the continuum.

Perrin and Mitchell (1997) pointed out that, although the amount of outcome

research has expanded rapidly within the past ten years, the majority of research has

focused on the dependent, or outcome, variable: its choice, definition, and

measurement. The future of outcomes research will lie in optimizing targets of


opportunity to study organizational changes, such as the development of new

organizational corporate structures or mergers. They urged researchers to use the

outcomes from organizational changes to focus on studying inferences about

processes or outcomes. Administrative data sets are important in answering major

questions about complicated systems.

Hoover (1998) reviewed the literature relevant to reengineering, restructuring,

and redesign that occurred in response to managed care for the years 1987 through

1997. Seventy-six articles were identified initially, but case studies subsequently

were excluded because most were anecdotal in nature. Thirty-two research articles

and four review articles were included in the review. The theoretical and conceptual

approaches and the dependent variables that were used in the research studies were

analyzed in relation to evaluation of outcome measures. Authors of the critical

reviews consistently identified the lack of a common theoretical theme or of any

existing evaluation models. Hoover found that the empirical studies reviewed

contained inadequate information to replicate the study methodologies. Thirteen of

the 32 articles did not cite a theoretical approach and the rest used a variety of

approaches, such as systems theory, group synergy, and a combination of

psychological and task inventory approaches.

According to Hoover (1998, p. 16) outcomes can be compared with “gold

standards, competitors, or prior goals” and are defined as “a measurement of the

accomplishments and impact of a service, program, or policy”. The evaluation

variables or outcomes that had been used in previous studies were reviewed and an


evaluation framework for work redesign was proposed. The author stressed that

comprehensive evaluation of work redesign should include the components of health

outcomes, costs, and satisfaction. In addition to evaluation of individual units, it is

imperative to include evaluation of impact upon the entire system and to gather

longitudinal information so as to have a baseline with which to compare results after

implementation of design or redesign.

The early literatures on the impact of organizational structure/context and on

patient outcomes developed independently of each other. Research on organizational

context, especially in hospitals, was concentrated on understanding cost differences

and several nurse researchers conducted studies about causes for periodic nursing

shortages. As noted earlier by Hoover (1998), studies on outcomes within hospitals

and other health care organizations were focused on methodological issues. Studies

were directed at measuring the characteristics of patient populations, such as severity

of illness, and determining the appropriateness of various outcomes (Aiken,

Sochalski, & Lake, 1997).

Mitchell and Shortell (1997) stated that many administrators in health care

institutions and clinicians believe that patient care outcomes are influenced by the

interaction between disease-specific clinical treatments and the organizational

structures and processes that support clinical care delivery. They reported that the

most common quality of care outcome indicators utilized in clinical trials and

correlational studies have been mortality, morbidity, and adverse effects. A review of

81 research articles that focused on the interaction between mortality and adverse


events found adverse events to be the more sensitive indicator in relation to the way in

which care was organized.

By the late 1990s many health care administrators and clinicians had come to

believe that patient care outcomes are influenced by the organizational

structure/context and the processes that support clinical care delivery, such as

provider-patient relations and clinical decision-making (Aiken, Sochalski, & Lake,

1997; Mitchell & Shortell, 1997). Multiple studies since that time have concentrated

on the effect of changes in context, such as restructuring, and changes in processes,

such as nurse staffing and the coordination of care, upon patient outcomes.

During the past 15 years, there has been an increased emphasis on clinical and

healthcare system outcomes that have had an impact upon all segments of the health

care industry. Nursing researchers have focused on the identification, definition, and

measurement of outcome variables. Within hospitals, many nursing practice

administrators have initiated various types of work redesign in attempts to improve

clinical and system outcomes, such as improved quality, enhanced efficiency, and

desired patient outcomes at lower costs (Mitchell, 1993; Shortell, Gillies, & Devers,

1995).

Mitchell (1993) cited Donabedian’s theory that quality of care is based on a

triad of structure (how care is organized), process (how care is delivered and

documented), and outcomes (how care helped the patient). The author maintained

that there has been a lack of system-level thinking in the United States in health care

policy and clinical thinking, as evidenced by the lack of databases for evaluating


health care outcomes. Florence Nightingale demonstrated the utility of studying a

population outcome (i.e., mortality) as a measure of surgical care of the British Army.

Mitchell believed that nurses are well positioned to link structural, process, and

clinical outcomes, based on their education and “experience in coordinating care

along the primary to tertiary continuum” (p. 6). Rather than focusing on nursing

specific outcomes, nurses should extend them in designing and providing coordinated

care systems that meet the needs of individual patients and populations.

Interdisciplinary Collaboration

Since the early 1990s, there has been a growing interest in determining the

impact of interdisciplinary collaborative decision making upon patient outcomes. A

seminal study was conducted by Knaus, Draper, Wagner, and Zimmerman (1986) and

utilized the Apache II methodology. In a retrospective study of 13 tertiary care

hospitals, they explored the impact of physician - nurse collaboration upon patient

mortality. The interaction and coordination that occurred between medical and

nursing staff was offered as an explanation for the difference between expected and

observed deaths found for intensive care unit (ICU) patients. Hospital ICUs where

staff reported more positive collaboration and communication had 41% fewer deaths

than the predicted death rate and hospital ICUs where staff reported less collaboration

and communication had a death rate 58% higher than predicted (Curtin, 2003).

A second ICU study, conducted by Mitchell, Armstrong, Simpson, and Lentz

(1989), was an American Association of Critical-Care Nurses demonstration project.

The aim of the study was to examine the relationship between organizational


attributes and patient outcomes. The impact of organizational process on

interdisciplinary relationships was measured by key indicators, such as flow of

information and nurse – physician collaboration. Interdisciplinary relationships were

one of five organizational characteristics that were found to be significantly correlated

with high patient satisfaction, low patient mortality rate, high staff satisfaction, and

low staff turnover rate.

A third ICU study, by Baggs, Ryan, Phelps, Richeson, and Johnson (1992),

was a prospective study about the effect of collaborative decision making by

physician and nurse concerning transfer from a medical ICU on patient mortality and

readmission. The researchers discovered that the patient predicted risk of a negative

outcome was 16% when the nurse reported no collaboration in decision making and

was significantly decreased to 5% when the nurse reported full collaboration.

Resident report of interdisciplinary collaboration was not significantly associated with

patient outcomes.

In order to assess whether the findings of the study by Baggs et al. (1992) were

generalizable to other types of ICUs, Baggs et al. (1999) conducted a follow-up

prospective study that replicated the earlier work in a university teaching hospital

surgical ICU, a community teaching hospital medical ICU, and a community hospital

mixed medical – surgical ICU. Findings for this study showed: (a) the reports of

collaboration perceived by medical ICU nurses were associated positively with patient

outcomes, (b) there were not any other significant correlations found between the

reports of care providers (nurses in the other two units, attending physicians or


residents) and patient outcomes, and (c) on all three units there was a perfect rank

order association between unit-level organizational collaboration and patient

outcomes. Baggs et al. (1999) speculated that medical ICU nurses might differ from

other ICU nurses because of the complexity of the patients and the impact that

collaboration has in complicated, uncertain situations.

The Joint Commission on Accreditation of Healthcare Organizations

(JCAHO) views the interdisciplinary team as an important standard of high quality

care and requires documentation that demonstrates ongoing coordination of care

between health team members.

Interdisciplinary collaborative decision making between nurses and physicians

has been found to have an impact on a variety of patient and nursing outcomes,

including length of stay, mortality rates, and staff turnover (Curley, McEachern, &

Speroff, 1996; Knaus, Draper, Wagner & Zimmerman, 1986; and Mitchell,

Armstrong, Simpson and Lentz, 1989). It is noteworthy that these outcomes have

also been found to be influenced by staffing levels of registered nurses (Curtin, 2003).

More recently, the importance of the interdisciplinary team has been emphasized

within the case management literature (Crowell, 1996; Powell, 2000; Sparbel &

Anderson, 2000).

Case Management Nursing Care Delivery Model

Reengineering efforts have reshaped both the content and context of

professional nursing practice. Nursing content refers to the direct and indirect

activities involved in nurses’ work. Nursing context refers to the organizational


structures and processes that determine how policy and procedure decisions about

how nurses practice are made (Blouin & Tonges, 1996).

Patient care delivery models have become multidisciplinary and organized

around work processes rather than functional models. This approach has led to

changes in the context of nursing practice and several contemporary nursing redesign

initiatives have emerged since the late 1980s, such as differentiated practice,

outcomes-based practice, network-based caregiver continuity, and other hybrid

models, as organizations explored new ways in which to restructure nurses’ work

(Blouin & Tonges, 1996). Case management is a patient care delivery model that is

focused on the achievement of continuity of care.

Case management is a process that has evolved in conjunction with various

work redesign initiatives at the nursing practice and the institutional level. According

to Powell (2000), many experts initially believed that case management, as a practice

model, would have a life span of about five years. However, time has shown it to be

more enduring.

In the United States, case management has become the established link

between managed care and patient care. The role of the case manager has expanded

rapidly because of the complexity of healthcare insurance benefit packages and

reimbursement rules. The Case Management Society of America (CMSA) expanded

the definition of case management to reflect a broader view that is relevant across

multiple models of case management. Case management is defined as “a

collaborative process which assesses, plans, implements, coordinates, monitors, and


evaluates options and services to meet an individual’s health needs through

communication and available resources to promote quality, cost-effective outcomes”

(CMSA, 2000, p. 5). When CMSA revised the definition in 2002, although the word

“coordination” is not included in the definition, the terms “facilitation” and

“advocacy” were used. These terms are seen as core characteristics of coordination of

care (Bender, 2003). One of the primary functions of case management is to achieve

coordination of care, which is central to essentially every published definition of case

management (Bender & Schmitt, 2005).

Case management is expanding internationally, as evidenced by the creation

of the Case Management Society International. Countries that provide universal

health coverage are expressing interest in integrating all aspects of health within

evidence-based disease management programs. As the United States healthcare

industry has evolved towards “integrated care delivery”, other countries have

developed similar programs to control fragmentation and costs. For instance, the

Netherlands now has a concept called “transmural care” and England has developed

“shared care” (Powell, 2000).

The role of the case manager (sometimes in a narrower context, called a "care

coordinator") has expanded and evolved over time. Although case managers have

continued to come from multiple healthcare disciplines, professional nurses have

predominately functioned in the role of case manager (Powell, 2000). In addition to

coordination activities, the case manager role often includes direct care activities,

patient teaching, and supervision of other team members.


Based on educational preparation and the escalating complexity of healthcare,

advanced practice nurses are increasingly identified as best suited for the multifaceted

role of case manager (Sparbel & Anderson, 2000). Advanced practice nurses (APNs)

are educated to develop and accomplish functions that help to achieve the best

outcomes for patients, providers, and payers (Taylor, 1999). These APN

competencies traditionally have included the ability to provide direct care, expert

guidance, coaching, and ethical decision-making. In addition, their educational

preparation prepares advanced practice nurses to provide consultation, collect and

analyze data, conduct system assessment, and develop programs for change. These

competencies and skills are increasingly in demand as health care complexity

escalates (Mahn & Spross, 1996).

Continuity of care and the interdisciplinary team approach have become

important aspects of the case management process. Sparbel and Anderson (2000)

conducted an integrated literature review on the concept of continuity of care, based

on relevant nursing literature published between 1990 and 1995. Continuity of care

commonly has been viewed by nursing as an outcome or a goal of the nurse-patient

relationship that is accomplished through a process, such as care coordination

activities. Continuity of patient care within a health care institution or system may

extend across multiple settings, providers, and time. The authors found that the

concept of continuity of care is an evolving one that is connected to a host of related

concepts through relationships that are complex and unclear. Because the concept is

multifactorial, there is not a consistent definition of the concept. The literature


showed that it is influenced by a variety of factors, such as the environment, system,

communication, patient, and professional.

The Joint Commission on Accreditation of Healthcare Organizations

(JCAHO) views continuity of care as an important standard of high quality care and

requires documentation that demonstrates ongoing coordination of care between

health team members and discharge planning to link with other parts of the health

care system. Case management is an example of a practice model designed to ensure

continuity of care across interdisciplinary collaborative decision making. Case

management expands on the role of the nurse from the perspective of both the total

nursing care and the primary nursing care delivery models. Case management builds

on the total nursing care model in that the nurse is responsible for ensuring continuity

of care occurs, often by collaborating or delegating activities to other interdisciplinary

team members rather than by managing continuity for nursing care for an assigned

shift. Case management is also an expansion of the nurse’s role in that the nurse is

accountable for ensuring interdisciplinary team outcomes are met by the team,

whereas in the primary nursing care delivery model, the nurse is accountable for

providing whatever nursing care the patient needs within a 24-hour nursing care plan.

Summary

In order to be regarded as integrators of health care in the 21st century,

nursing leaders needed to be responsive to the multiple changing factors occurring

within the population in terms of demographics and consumer activation,

governmental initiatives, and the health care system. It was important for nursing


leaders to consider changes in population demographics so that they could anticipate

the kinds of patients who would be entering the health care system and to develop a

plan to meet their health care needs effectively. In addition, the concerns of

consumer activists needed to be heeded carefully and additional strategies developed

to remain responsive to their concerns. Government and JCAHO regulations

demanded timely and ongoing process improvement if quality services were to be

provided in an effective and efficient manner. Nursing leaders also needed to

collaborate with their medical colleagues in understanding and applying the theory of

complex adaptive systems constructively if they were going to be proactive

participants in making fundamental adaptive changes to the health care system.

The emphasis on health care outcomes influenced both nursing education and

nursing practice. As patient acuity increased in the inpatient setting, staff nurses

needed to focus on ensuring the coordination of nursing care. Case management

expanded the coordination of care responsibilities of nurses who functioned in the

case manger role. Interdisciplinary collaboration within complex systems of health

care and involving many types of care providers became a topic of nursing research.

Coordination of Care (2000 to the Present)


Health care costs continue to escalate as the United States moves into the 21st

century. According to Bodenheimer (2005a), the United States health care system is

the most expensive in the world and health care costs are growing rapidly, accounting

for 14.9% of gross national product for health care in 2002. Of the four major actors


that impact on health care (i.e., purchasers, insurers, providers, and suppliers), the

sectors with the most rapid growth are administrative costs of private health insurance

and cost of prescription drugs.

A key driver of health care expenditure growth is the spread of technologic

advances. New technologies are generally associated with increased costs as they

require more capital, more labor, and more expenses related to the spread of

knowledge. The United States incurs higher costs than many other countries because

the spread of innovations is relatively unrestrained and is associated with higher

prices per unit of service. Many developed countries limit the speed that new

technologies diffuse through the system through cost containment controls, such as

nationally coordinated policy on health technology assessment (Bodenheimer, 2005b).

In addition to high and rising health care costs, consumers voice concerns about lack

of both safety and quality in health care. These concerns led to a study by the Institute

of Medicine to address medical errors and needed changes in the practice of medicine.

In 2001, the Institute of Medicine (IOM), in its report, To Err Is Human:

Building a Safer Health System, reported that approximately 98,000 hospitalized

Americans die each year as a result of errors in their care. A second report, entitled,

Crossing the Quality Chasm: A New Health System for the 21st Century, was

published in 2001 and focused on how the care delivery system could be adapted to

better meet the needs of the people it served (Institute of Medicine, 2001).

The abundance of care errors became a concern to government policy makers,

JCAHO, and health care consumers. Based on the request of the federal government,


the Institute of Medicine published a report in 2004, entitled, Keeping Patients Safe:

Transforming the Work Environment of Nurses, which addressed the changes needed

in the work environment and working conditions of nurses and other health care

workers to improve patient safety.

According to Eddy (2005), the concept that patient care should be based on

evidence-based medicine has spread throughout the medical community over the past

15 years. Two fundamental assumptions were found to have major flaws: 1) that each

physician would use clinical judgement, based on education, relevant research,

exposure to colleagues, and individual experiences to make sound clinical decisions,

and 2) that medical practices were based on current good evidence. Medical

organizations began to endorse the development of evidence-based clinical practice

guidelines and medical literature to emphasize evidence-based individual decision

making. Eddy (2005) proposed that evidence-based guidelines should be developed

by multidisciplinary teams, using explicit rigorous methods, to address the needs of

specific populations. These clinical practice guidelines should be used by health care

decision makers as resources in providing evidence-based care to individual patients.


Nurse Staffing

Given widespread concerns about patient safety resulting from care errors and

the critical role of nurses in patient safety, as reported in the Institute of Medicine’s

2001 and 2004 reports, several nurse researchers began to investigate the impact of


nurse staffing on patient outcomes and how characteristics of organizations influence

nursing staffing patterns.

Registered nurses and nursing assistants account for approximately 54% of all

health care workers and provide patient care in all locations in which health care is

delivered. The vigilance of nurses has been shown to protect patients against errors.

Research has also shown that patient outcomes are influenced by (a) the presence of

appropriate levels of nursing staff, and (b) the role of nurses interacting and

collaborating with physicians and interdisciplinary teams (Curtin, 2003; IOM, 2004).

As the complexity of health care continues to increase, so does the amount of

time spent by registered nurses in the coordination of patient care. Patients may

receive care (a) from multiple providers with specialized expertise and who function

in diverse roles, (b) in a single or multiple episodes of care, (c) from multiple units

during an inpatient stay, such as ED, ICU, step-down unit, and general

medical/surgical unit, and (d) in multiple sites, such as ambulatory clinics, skilled

care facilities, and home care agencies.

In addition to the amount of time that nurses spend in providing direct patient

care, they must also ensure that efficient and effective discharge planning and

patient/family education is completed prior to discharge. The coordination of care

activities done by nurses, which are necessary to ensure that care processes are

completed at the optimum time in the patient’s hospitalization and to prevent gaps in

care, are often classified as indirect patient care. It is estimated that staff nurses spend


as much as 25-45% of their time in indirect care functions. This means that nurses

have less time available for the provision of direct patient care (IOM, 2004).

Two other indirect care activities also have continued to increase over the past

decade: documentation and supervision. As federal, state, insurance, and institutional

regulatory requirements increase, nurses are required to spend an increasing amount

of time on documentation of nursing work, including coordination of care activities.

As a consequence of a demand for more nurses as technological advances increase,

nurses are supervising an expanded number of licensed and unlicensed nursing

personnel. In organizations where nursing care services have been decentralized to

the unit level, nurses may be required to supervise non-nursing staff as well (IOM,

2004).

The additional time that nurses need to spend in indirect activities, in

conjunction with the restructuring/redesign initiatives that many hospitals have

implemented to become more efficient, has had an impact on nursing care delivery

models. The Institute of Medicine (2004) reported that these changes have been

associated with nurses’ perceptions that they have less of a voice in patient care

decisions, that clinical nursing leadership has been reduced and less able to represent

nurses’ interests, and mistrust in hospital administration.

Maddox, Wakefield, and Bull (2001) addressed the IOM recommendations

that have implications for nursing education. First, they suggest that nurses ought to

receive training within interdisciplinary teams when their role requires interdependent

functioning with team members. Changes in nursing educational curricula and


clinical practicum experiences could foster knowledge and appreciation of the

contributions and dependencies of other team members, increase mutual commitment,

and encourage use of collective skills of the team to problem solve when errors occur.

Second, they recommend creating a working culture that facilitates open

communication, regardless of differences in authority. And third, because errors are

usually the result of poorly designed systems, advanced practice nurses need to be

prepared with quantitative and analytic skills in systems analysis.

Based on their educational preparation, advanced practice nurses fulfill many

specialized clinical roles in the acute care setting and their presence has led to more

complex nursing care delivery models. Regardless of whether they are educationally

prepared to be a clinical nurse specialist or a nurse practitioner, either type of

advanced practice nurse has specialized skills that enables them to assume a variety of

roles, such as case manager, care coordinator, educator, researcher, or nurse

administrator (Hamric, Spross, & Hanson, 1996).

The challenge for nursing leaders who are redesigning the nursing care

delivery model while ensuring patient safety will be to: balance the tension between

efficiency and patient safety; create and sustain trust of staff; manage the change

process; involve staff in decision making about work design and work flow; and, use

evidence-based management to establish the hospital/health care system as a “learning

organization” (IOM).

Nurse researchers have studied aspects of nurse staffing that impact on patient

outcomes. Curtin (2003) conducted an integrated analysis of research studies


examining the effects of nurse staffing and other related variables on patient and

nursing outcomes. The author concluded that patient outcomes, such as length of

stay, medical errors, patient mortality, and nursing outcomes, such as job

dissatisfaction and nursing turnover, were significantly impacted by nurse staffing.

The following studies are examples of patient and nurse outcomes that have been

linked to appropriate nurse staffing levels.

Aiken, Sochalski, and Lake (1997) referenced two studies they had conducted

illustrating that organizational traits, targets of opportunity, and natural experiments

can be evaluated for their impact on outcomes. The first study involved 25 hospitals,

17 of which were designated as magnet hospitals. They found that the presence of a

variety of nursing job characteristics (i.e., levels of autonomy, control, and good

nurse-physician relations) were higher in magnet hospitals than they were in non-

magnet hospitals. A similar study was conducted in 20 hospitals with dedicated

AIDS units and with multi-diagnosis units to evaluate differences in outcomes. There

was greater patient satisfaction and a lower level of staff burnout in dedicated AIDS

units than in the multi-diagnosis units.

Sovie and Jawad (2001) conducted a study in medical and surgical units in 29

university teaching hospitals that had undergone reengineering. An increased amount

of care hours worked per patient/day by registered nurse were associated with higher

rates of patient satisfaction with pain management and lower rates of patient falls. An

increased amount of care hours worked per patient days by all nursing staff (i.e,


registered nurses, unlicensed assistive personnel and others) was associated with

lower rates of urinary tract infections.

Needleman, Buerhaus, Mattke, Stewart, and Zelevinsky (2002) utilized

administrative data from medical and surgical patients in 799 hospitals in 11 states.

They found that an increased number of absolute care hours per patient day by

registered nurses, or an increased proportion of total hours of care per patient day

provided by registered nurses, was associated with six patient outcomes for medical

patients: shorter length of stay and lower rates of upper gastrointestinal bleeding,

urinary tract infection, pneumonia, cardiac arrest, shock, and failure to rescue. In

surgical patients, an increased level of registered nurse hours was associated with

lower rates of both urinary tract infection and failure to rescue.

Aiken, Clarke, Sloane, Sochalski, and Silber (2002), utilizing administrative

discharge data for surgical patients from 210 Pennsylvania hospitals and nursing

surveys, found that each additional patient assigned per nurse had an impact upon

patient outcomes and nurse retention in hospital practice. They found that in hospitals

having higher patient-to-nurse ratios (a) surgical patients had higher rates of risk-

adjusted 30-day mortality and failure to rescue and (b) nurses reported higher levels of

burnout and job dissatisfaction.

Staffing levels of registered nurses have been found to influence a variety of

patient and nursing outcomes. In two of the studies examined here, investigators

found a correlation between nursing staff levels and patient outcomes (length of stay,

mortality rate) and nursing turnover rates.


Evidence-Based Nursing Practice

Ingersoll (2000) maintains that evidence-based medicine/practice is an

important buzzword for the decade. In considering its relevance to nursing, she

discusses concerns voiced by nursing leaders and educators that include: (a) use of the

term as being synonymous with nursing research, (b) that randomized trials have been

the only studies worth considering and that other types of quantitative designs and

qualitative studies are viewed as being of lesser value, (c) that evidence-based

decision making lacks a theoretical foundation, and (d) that there might be ethical

consequences to evidence-based practices if the patient’s needs and preferences are

not considered in the decision making.

According to Mateo (2001), case managers are in crucial positions to

incorporate evidence-based practice into the delivery of care. In order to integrate

evidence-based guidelines and practices into their care, they need to systematically

obtain data to provide evidence, monitor the use of evidence-based practice, and to

evaluate the need for evidence-based practices to improve patient outcomes. It is

suggested that case managers who work within interdisciplinary groups to adopt

evidence-based practice benefit because each team member contributes unique

perspectives to the process.

As case managers’ roles include the use of critical paths and variance

management, they are in an ideal position to integrate the research process in

evaluating outcomes of care. The case manager, patients, and their families benefit

from the use of evidence-based practice because it enhances the case manager’s


ability to coordinate care in the most efficient and cost effective way. Case managers

benefit because they become recognized for their use of research-based practice, their

practices can be used to measure outcomes of care, and they have a basis for assessing

changing health care trends (Mateo, 2001).

According to Pravikoff (2006), information literacy (i.e., the ability to

recognize the need for information, to find it, evaluate it, and to incorporate it into

practice) is an important component of evidence-based practice. This requires

competency in the use of computers. In a nationwide survey, supported by the AAN

Expert Panel on Nursing Informatics, the author found that 50% of American nurses

are not familiar with the concept or the value of evidence-based practice nor had they

been trained in search techniques. Pravikoff suggests that nursing educators shift

paradigms from teaching courses about evidence-based practice to teaching courses

that entrench the student in information literacy and evidence-based practice, with

each subsequent course building on skills learned in previous courses.

Coordination of Care

The concept, coordination of care, has been part of health care language for

many years and considered to be an essential component to achieve quality care

outcomes. Although the term is used widely, there has been a lack of clarity about the

characteristics of the coordination of care processes used in health care and an overlap

with other related terms such as cooperation and collaboration (Bender, 2003).

Definitions. Many of the definitions of coordination of care focus on the

activities of coordination, such as facilitating, orchestrating, putting together


resources needed by patients, negotiation, patient advocacy, integrating and regulating

care activities (Bender & Schmitt, 2004). The JCAHO, in their patient safety and

medical/health care reduction standards, have recognized that a “coordinated

“approach to care is needed to reduce the commission of care errors and to prevent

omissions of care (JCAHO, 2001).

Kim (1998) developed a conceptually advanced definition that described three

characteristics of coordinated processes of care: cumulation, complementarity, and

contiguity. Cumulation refers to the summative (i.e., additive rather than repetitive)

effects of nursing care provided by the patient’s care providers. Complementarity

refers to how nurses need to coordinate their work in almost invisible ways that do

not contradict or replace each other, but rather complement each other’s efforts.

Contiguous processes among care providers result in meeting the patient’s care needs

in a logical, systematic progression, while maintaining “streamlined harmony among

various activities” (p. 13). Activities are linked in the optimal order, appear seamless

and should lead to improved patient outcomes (Bender & Schmitt, 2004).

Related concepts. Bender and Schmitt (2004) have compared and contrasted

the similarities and the differences between cooperation, coordination of care, and

collaboration. Communication and interdependence are essential characteristics of all

three processes.

Cooperation involves the process of working together with another person or

persons for a common care purpose, is more global than the other processes, and

requires minimal care integration. Coordination of care differs from cooperation in


that its goal is greater care integration. It requires a higher level of interaction in

provider relationships, more specific provider processes, increased interdependence,

and more specific communication between care providers. Collaboration involves

more complex relationships (double feedback loops) between care providers that are

mutual and reciprocal. The resulting “group coordination” requires more complex

interdependence and communication strategies than either relationships that involve

only cooperation or coordination of care. Cooperation and coordination of care are

essential components of collaboration (Bender & Schmitt, 2005).

Mechanisms of care. Bender and Schmitt (2005) have identified three

essential elements that need to be present before effective coordination of care can

occur. The first element is that the health care provider must have assessed the

patient’s needs and desires and determined an appropriate plan of care. The second

needed element is that health care providers communicate and develop relationships

with other health care providers, patients, and their families. The third element is that

the health care organization is striving to achieve shared objectives, by fostering

unity/integration of efforts among health care providers, patients, and families.

Coordination of care is accomplished through multiple mechanisms, which

may be used in a variety of combinations to address a specific situation. Van de Ven

and Ferry (1980), Young et al. (1997), and Strayer and Charns (1981) are cited by

Bender and Schmitt (2005) as having categorized the mechanisms into two major

groups: programming (or standardized) methods that are impersonal or


“technostructural” methods of coordination and personal (feedback), group

communication, or “social process” methods.

Programming mechanisms (i.e., the standardization of work and skills) are

most efficiently used for routine or predictable coordination of care activities that are

clear and defined (Aliotta, 2003; Bender & Schmitt, 2005). Standardized work

methods may range from quite impersonal to less impersonal, such as rules,

regulations (e.g., JCAHO), policies, procedures, patient care guidelines, protocols,

and computerized information systems (Bender & Schmitt, 2005). As consumer

concerns about patient safety have escalated, JCAHO regulatory requirements about

coordination of care have continued to increase. These requirements have served as

mandates for health care organizations, and especially hospitals, to facilitate and

strengthen the programming mechanisms that are utilized to ensure coordination of

patient care within a safe environment.

Feedback and information exchange mechanisms are most effective when high

levels of uncertainty exist in situations. These mechanisms also range from the least

complex to the most complex methods of communication, such as supervision

hierarchies, peer interactions, teamwork, and collaboration (Bender & Schmitt, 2005).

Feedback mechanisms speak to the processes that are utilized to achieve

coordination of care. Teamwork, whether it occurs formally, such as in

interdisciplinary rounds, or informally amongst care providers is the key feedback

element to accomplish coordination of care. Collaboration occurs when team

members use feedback to develop comprehensive interdisciplinary plans of care for


patients with complicated health care needs (Bender & Schmitt, 2005). Aliotta (2003)

noted that programming mechanisms of coordination are also needed in order for

higher levels of coordination to occur.

In the past two decades, nursing and health care have experienced a state of

rapid fluctuation due to multiple internal and external factors. Case management

emerged as a work force strategy that incorporates many of the programming and

feedback mechanisms of coordination of care. Efficient coordination of care requires

both programming and feedback mechanisms. Programming provides the structure

for dealing with routine situations and feedback provides the process for team

members to develop an integrated plan of care to resolve complex situations.

Interdisciplinary teams. The Institute of Medicine has recommended that

there is a need to improve nurses' work environments by developing multiple,

mutually reinforcing changes in patient safety practices that will reduce error. In

other words, leadership in health care organizations "will need to assure the effective

use of practices that (1) balance the tension between production efficiency and

reliability (safety), (2) create and sustain trust throughout the organization, (3)

actively manage the process of change, (4) involve workers in decision making

pertaining to work design and work flow, and (5) use knowledge management

practices to establish the organization as a "learning organization." (p. 8). Several

recommendations have been made about ways in which to maximize nursing

workforce capabilities. For example, the IOM committee made a recommendation

that health care organizations "should take action to support interdisciplinary


collaboration by adopting such interdisciplinary practice mechanisms as

interdisciplinary rounds, and by providing ongoing formal education and training in

interdisciplinary collaboration for all health care providers on a regularly scheduled,

continuous basis (e.g., monthly, quarterly, or semiannually)" (IOM, 2004, p. 12),

based upon evidence that inconsistent interprofessional collaboration occurs among

nursing staff and other health care providers.

In order to have an in-depth understanding about the effectiveness of

interdisciplinary team collaboration in ensuring patient safety and other related

outcomes, the IOM committee commissioned a review of published research as part

of the larger study. Nurses interact with other members of the interdisciplinary team

in a vast variety of ways to accomplish coordination of care activities, ranging from

informal interactions with multiple nursing and other professional team members that

occur during the course of providing care to being a member of a formal, structured

interdisciplinary team (Ingersoll & Schmitt, 2004). Schmitt (2001, p.51) noted that

“Team care is not a single homogenous treatment variable. Teams, as work groups,

vary in the quality of their functioning... collaboration is not a dichotomous variable,

simply present or absent, but present in varying degrees”. Although the

conceptualization of interdisciplinary collaboration and team care need refinement by

researchers within health services, organizational and psychological sciences, there is

consensus that interdisciplinary collaboration is multidimensional (IOM, 2004).

Two of the hallmarks of effective interdisciplinary collaboration have been

identified as the presence of necessary precursors and characteristic behaviors.


Individual clinical competence and mutual trust and respect are both considered

essential for interdisciplinary collaboration to occur. Functional interdisciplinary

collaboration requires a grouping of several typical behaviors, including (a) shared

understanding of goals and roles; (b) effective communication; (c) shared decision

making; and (d) conflict management (IOM, 2004).

The research literature indicates that supportive organizational structures and

processes can facilitate the building and nurturing of interdisciplinary collaboration in

a variety of ways. Three of the processes directly relate to the structure and function

of the interdisciplinary team. First, leadership modeling of collaborative behaviors

has been found to positively impact how medical staff relates to nursing staff. For

example, Disch, Beilman, and Ingbar (2001) reported on the development of a

partnership between the critical care nurse manager and the medical director as being

instrumental in creating a healthy and effective work environment (IOM, 2004).

The second process relates to the design of work and workspace to facilitate

collaboration. Work is designed so that interdisciplinary team members have time to

participate in collaborative activities, such as interdisciplinary team rounds, and

workspaces are designed in ways that promote the physical proximity of team

members so that collaboration can occur (IOM, 2004).

The third process involves instituting interdisciplinary practice mechanisms.

Structured interdisciplinary forums, such as interdisciplinary rounds, have been found

to be effective in improving patient care (IOM, 2004). Curley, McEachern, and

Speroff (1998) conducted a randomized, controlled six-month firm trial on the impact


of interdisciplinary rounds on the inpatient medical services. They found that the new

multidiscisciplinary rounds had a significant impact over the traditional physician

work rounds process in decreasing both patients' length of stay and costs. The

promotion of interdisciplinary information sharing, such as interdisciplinary clinical

pathways, has also been found to facilitate interdisciplinary practice (IOM, 2004).

Health care organizations utilize structural, or programming mechanisms, of

care in order to ensure that patient care is coordinated across multiple care providers,

multiple episodes, and multiple sites. Frequently used structural mechanisms include

adequate nurse staffing, formal interdisciplinary teams, and structures to facilitate

interdisciplinary collaboration. Organizational support is instrumental in providing

the structure for formal and informal interdisciplinary collaboration.

Chapter Summary

The goal for this chapter has been to review the evolution of nursing care

delivery models in the United States. Interdependence exists between relevant

societal, economic, and demographic factors, healthcare organizations, and nursing

education, research, and practice. Many healthcare organizations have responded to

external demands from consumers and state and federal governments by periodically

implementing restructuring or reengineering interventions.

External governmental and health care trends and requirements have formed

the context for major developments within nursing education and nursing practice.

The struggles of nursing educators to define the conceptual domain of nursing and to

move nursing forward as a discrete discipline led to the development of nursing


theories, such as those of Peplau, Orlando, and Travelbee. Subsequent theory

development has been influenced by changes within healthcare and nursing practice.

Over the years, multiple nursing care delivery models have been instituted by nursing

administrators as they have adapted to the challenge of incorporating nursing

theoretical frameworks into practice while dealing with the constraints of their times.

In the past two decades, nursing leaders also have adapted a variety of practice and

redesign models, such as case management and differentiated practice, which further

formalized the role of the professional nurse.

Traditionally, professional nurses have been responsible for assessment of the

patient’s physical, psychological, and social needs, coordination of patient care,

provision of diagnostic and treatment activities for which they have responsibility,

and treatment of palliative needs that are situationally derived. World War II

precipitated the development of technological advancements and the expansion of

intensive care units, and the role of professional nurses has expanded steadily over the

years to include increased management of physiological needs.

A larger proportion of professional nurses’ time has needed to be spent in

direct care activities because managed care and escalating healthcare complexity have

led to additional structuring of the role of professional nurses, i.e., creation of the case

manager role. Both the unit nursing team and the nursing case manager have the

opportunity to develop and utilize a relationship with the patient to ensure that the

patient’s needs are being identified, addressed, and met. The educational preparation

of advanced practice nurses has also placed them in an ideal position to understand


and manage patient care needs from a holistic perspective and to function as case

managers in complicated healthcare environments.

Healthcare organizations, nursing practice leaders, and nursing researchers

have become increasingly interested in the identification of system and clinical

outcomes that will indicate whether or not organizational processes that support

clinical care delivery are successful in increasing the effectiveness and efficiency of

patient care. Nurses and other health care researchers have identified, defined, and

measured a variety of outcome variables. However, studies to date have been limited

because they were anecdotal, focused on the identification of clinical or system

variables, and/or used individual inpatient units as the unit of analysis.

As new frameworks develop within organizations in response to rapid changes

within health care, their leaders and agents will be required to find ways in which to

deal with the discomfort that is associated with change and creative activities. The

framework of complex adaptive systems may be helpful in making sense of

experiences within organizations in ways that are congruent with that experience and

how individuals feel about it.

Research studies to date have not taken into account the influence that external

context has upon care delivery systems. In today’s systems where change is rapid and

complex in nature, organizations that have a framework that fosters adaptive

strategies are more likely to be successful. Although it may be difficult to determine

if a program or an organization is successful because of the number and complexity of


variables that are involved, it is important to study the experience in order to reflect

on what variables have an influence on outcomes.

New methodology is needed to study nursing models of care in complicated

systems and to determine inferences about organizational processes. The use of

administrative data sets could provide an opportunity to study longitudinal data about

multiple units within one institution. Research needs to be done to evaluate the

influence of new innovations upon clinical outcomes.

Increased understanding is needed related to the roles of nurses in promoting

coordination of care activities and how these roles integrate within the larger

framework of the unit interdisciplinary team. The nursing case manager is an integral

part of the interdisciplinary team and often is the person who is accountable for

coordinating health team rounds. The research related to this dissertation focuses on

outcomes of new models of care coordination which are complex, adaptive, and

dynamic in nature.

coordinating care delivery models 9

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