Models of care in nursing: a systematic reviewjbr_287 324..337

Ritin Fernandez RN MN (Critical Care) PhD,1,2 Maree Johnson RN BAppSci MAppSci PhD,3,4 Duong Thuy Tran BMed (Vietnam) MIPH (USyd)5 and Charmaine Miranda BPsycholgy6 1School of Nursing, Midwifery and Indigenous Health, University of Wollongong, Wollongong, 2Centre for Research in Nursing and Health, St George Hospital, Kogarah, 3Centre for Applied Nursing Research, Sydney South West Area Health Service, 4School of Nursing and Midwifery, University of Western Sydney, Sydney, 5School of Medicine, University of Western Sydney, Sydney, and 6Centre for Positive Psychology and Education, School of Education, University of Western Sydney, Sydney, New South Wales, Australia

Abstract Objective This review investigated the effect of the various models of nursing care delivery using the diverse levels of nurses on patient and nursing outcomes.

Methods All published studies that investigated patient and nursing outcomes were considered. Studies were included if the nursing delivery models only included nurses with varying skill levels. A literature search was performed using the following databases: Medline (1985–2011), CINAHL (1985–2011), EMBASE (1985 to current) and the Cochrane Controlled Studies Register (Issue 3, 2011 of Cochrane Library). In addition, the reference lists of relevant studies and conference proceedings were also scrutinised. Two reviewers independently assessed the eligibility of the studies for inclusion in the review, the methodological quality and extracted details of eligible studies. Data were analysed using the RevMan software (Nordic Cochrane Centre, Copenhagen, Denmark).

Results Fourteen studies were included in this review. The results reveal that implementation of the team nursing model of care resulted in significantly decreased incidence of medication errors and adverse intravenous outcomes, as well as lower pain scores among patients; however, there was no effect of this model of care on the incidence of falls. Wards that used a hybrid model demonstrated significant improvement in quality of patient care, but no difference in incidence of pressure areas or infection rates. There were no significant differences in nursing outcomes relating to role clarity, job satisfaction and nurse absenteeism rates between any of the models of care.

Conclusions Based on the available evidence, a predominance of team nursing within the comparisons is suggestive of its popularity. Patient outcomes, nurse satisfaction, absenteeism and role clarity/confusion did not differ across model comparisons. Little benefit was found within primary nursing comparisons and the cost effectiveness of team nursing over other models remains debatable. Nonetheless, team nursing does present a better model for inexperienced staff to develop, a key aspect in units where skill mix or experience is diverse.

Key words: evidence-based practice, nursing, systematic review.


Various models for the delivery of nursing care such as patient allocation, primary nursing and team nursing have been implemented over the past few decades. These models performed successfully in the workforce that mainly con- sisted of registered nurses (RNs). However, over the past 10 years, the healthcare environment in Australia and globally

has undergone significant changes mainly due to shortages of RNs and budget constraint.1 As a result, a major restruc- ture of the nursing workforce has been undertaken2 includ- ing filling RN positions with enrolled nurses (ENs), assistants in nursing and unlicensed carers.3

This study sought to provide evidence of the effectiveness of the varying models of care used in nursing, in particular, team nursing (group of nurses caring for a large group of patients for one shift) and patient allocation (one nurse caring for a small number of patients for one shift). This review will inform health service policy on when and how to apply differing nursing models of care within practice.

Correspondence: Professor Ritin Fernandez, St George Hospital, Kogarah, NSW 2217, Australia. Email: ritin.fernandez@ sesiahs.health.nsw.gov.au


doi:10.1111/j.1744-1609.2012.00287.x Int J Evid Based Healthc 2012; 10: 324–337

© 2012 The Authors International Journal of Evidence-Based Healthcare © 2012 The Joanna Briggs Institute

In Australia, the inclusion of the differing levels of nurses into the workforce has led to redefining the roles of RNs and ENs in order to maximise the resources during the shortage. For example, RNs have been given roles such as clinical supervision and ENs are permitted to administer medica- tions under the supervision of RNs. In some areas, ENs have extended roles including wound care.4

Several adaptations and combinations of the traditional models of patient care delivery have arisen in order to accommodate the changing roles of nurses and the various levels of nursing skill mix.5–8 These include team-oriented models such as partners in care9,10 shared care nursing,8,11

modular nursing and partners in practice.12,13 Evaluations of the various models of care delivery have demonstrated that a RN-predominant skill mix is associated with better patient health outcomes and lower mortality, improved quality of care and reduction in medication errors and wound infec- tions,14,15 which can be explained by RN’s ability to earlier detect patient deterioration and intervene timely.16 Other studies have found improvements in staff satisfaction, recruitment and retention of staff and reduction in sick leave, improved team spirit and a cleaner ward environment.17

Patient allocation models have also been implemented with the varying skill mix and in one study8 there was no difference in job satisfaction between a team-oriented model and patient allocation model. Communication between all members of nursing and interdisciplinary teams is believed to be a key element for the success of any care delivery models.18 In a study11 that compared a team-oriented and patient allocation model of care, there were no significant differences in communication at the 6-month follow up. One of the disadvantages of the patient allocation model in the current workforce is little capacity for supervising or teaching inexperienced new staff and the possibility of junior RNs and ENs being required to care for patients beyond their skills and experience.17

A recent report from the New South Wales Health follow- ing an inquiry into nursing services recommended the use of a team model for nursing care delivery.19 However, the deci- sion to change to a different model of care should be informed by existing evidence to support or refute the effi- cacy of the model. Although reviews have been previously undertaken evaluating the various models of care, these reviews have combined nursing care delivery models com- prising of all RNs (e.g., team nursing with all RNs and patient allocation with all RNs), as well as the various levels of nurse. In contemporary nursing practice, wards staffed with all RNs are fast becoming nonexistent.1 Therefore, the aim of this study is to undertake a systematic review of the literature to investigate the effect of the various models of nursing care delivery using the diverse levels of nurses on patient and nursing outcomes.


Inclusion/exclusion criteria This review included randomised and non-randomised con- trolled studies which compared different models of nursing

care involving nurses with varying skill mix. Reports pub- lished from the year 2000 and in the English language only were considered in this review. Studies that involved patients aged 18 years and over and nurses who worked in hospital settings were included. Studies undertaken in community settings and those involved midwifery practices were excluded. The focus of this review was on acute inpatient settings, and midwifery practice and community nursing represent unique contexts, warranting a discipline-specific systematic review. Studies that compared any models of nursing care delivery including team nursing, primary nursing, functional nursing and case management models were included. Studies that had all RN staffing were excluded unless they were compared with a mixed skill model. In the current health environment, having an all RN staffing in the hospital setting is highly unlikely1; therefore, these studies were excluded to reflect the current staffing skill mix. Patient-, nurse- and organisation-related outcomes were evaluated. Patient-related outcomes of interest were the following: (i) incidence of errors and adverse events including complaints, failure to rescue, falls, pressure sores, morbidity and mortality; (ii) length of hospital stay and readmission; (iii) quality of patient care; and (iv) patient satisfaction. The nursing outcomes of interest were the fol- lowing: (i) inter-professional communication, role clarity, professional development and support from senior staff; (ii) job satisfaction; (iii) staff attrition rate; and (iv) nursing documentation. Cost effectiveness was assessed as an organisational outcome. These outcomes were selected as the evidence14,15 demonstrates that nursing skill mix can have an impact on the outcomes listed.

Search strategy With the assistance of a qualified health librarian, the follow- ing databases were searched: Medline (1985–2011), CINAHL (1985–2011), EMBASE (1985 to current) and the Cochrane Controlled Studies Register (Issue 3, 2011 of Cochrane Library). The search terms used were nursing care delivery systems, nursing models of care, personnel staffing and scheduling, nurse–patient ratio and nursing service. A detailed description of the search strategy used can be obtained from the authors. Additionally, the reference lists and bibliographies of all possible studies and reviews were searched for further references. Relevant conference pro- ceedings, key word searching of the World Wide Web and grey…