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Overview of Nursing Practice Models

Carol S. Weisman, Ph.D./ National Center for Nursing Research

For purposes of this paper, the term “nursing practice model” refers to operational models for redesigning nursing practice for the provision of patient care in organizational settings, primarily hospitals and longterm care facilities. Though the models may be implemented organization-wide, they typically redesign nursing practice at the point of patient care delivery, that is, at the nursing unit level. Thus the models are distinguished from organization-level management innovations (such as clinical advancement programs or innovative pay systems) that do not specifically address care delivery.

Nursing practice models are innovative practice arrangements that differ from traditional models on one or more of the following structural dimensions:

  1. The degree to which the practice of individual nurses is differentiated according to education level or performance competencies;
  2. The degree to which nursing practice at the unit level is self-managed, rather than managed by traditional supervisors;
  3. The degree to which case management is employed; and
  4. The degree to which “teams” (either nursing or multidisciplinary) are employed. Many practice models contain more than one of these elements and also include elements of primary nursing.

A recent compendium of innovative nursing practice models (Mayer, Madden, and Lawrenz, 1990) includes the selected examples. These models, which have been evaluated to varying degrees, represent a wide variety of structural approaches to reorganizing nursing practice. Some have been motivated primarily by the need to address nurse staffing shortages, whereas others have been motivated primarily by the need to contain costs. Cost savings might be achieved through better coordinated care, through use of non-RN providers, or through reductions in turnover and replacement costs. Most of these models have been developed for, and field tested on, a small number of nursing units in one hospital, rather than hospital-wide or in multiple hospitals.

In addition to the models already described in the published literature, there are some ongoing evaluations of innovative models. Two research demonstration projects funded by the National Center for Nursing Research (NCNR) and the Division of Nursing are underway in New York and Arizona. The University of Rochester School of Nursing is implementing and evaluating an Enhanced Professional Practice Model for Nursing, designed to increase nurses’ control over practice at the unit level and to provide professional compensation.

The evaluation design includes five hospitals, experimental and control units, and a pretest-posttest design. Patient outcomes being studied include patients’ perceptions of the hospital experience, morbidity and mortality, and unplanned hospital readmission up to 30 days post-discharge. The University of Arizona College of Nursing is implementing and evaluating a unit-based Differentiated Group Professional Practice Model that includes three components: group governance (including participative management, staff bylaws, peer review, and professional salary structure); differentiated care delivery (including differentiated RN practice, use of nurse extenders, and primary case management); and shared values (including a culture-building process that values quality of care, intrapreneurship, and recognition for excellence in practice). The evaluation design includes three hospitals, demonstration and comparison units, and a 36-month followup. Quality of care outcomes include complications, medication errors, infections, and chart audits.

NCNR is also funding the evaluation of The Johns Hopkins Professional Practice Model. That model consists of a contract between a unit’s registered nurses and the hospital in which the nurses agree to provide 24-hour patient care on the unit for one year in exchange for unit self-management (including peer review, self-scheduling, and quality assurance), salaried compensation, and shared savings if the unit contains its costs.

The evaluation design is post-test only and includes 16 professional practice units and 8 comparison units matched for gross clinical area and unit size. The Professional Practice Model units include units in neurology, psychiatry, pediatrics, general surgery and several surgical specialties, two general operating rooms and labor and delivery. Process variables and patient outcomes studied include in-hospital mortality, medication errors, falls, length of stay, patient satisfaction with nursing care measured on the day of discharge, post-discharge perceived health status, unmet needs for care during the first two weeks after discharge, post-discharge unplanned health services utilization, and hospital readmission within 30 days. Post-discharge outcomes are included because the model was expected to improve discharge planning; the two-week post-discharge period was selected for study based on previous research on the effects of discharge planning on patients’ needs for care (Steinwachs et al., 1989). Our data are being analyzed now.

Twenty projects have been funded by The Robert Wood Johnson Foundation and The Pew Charitable Trusts in their program entitled “Strengthening Hospital Nursing: A Program to Improve Patient Care.” The implementation phase of these projects began in the fall of 1990, so definitive descriptions of the practice models being tested are not yet available. According to the projects’ proposals, the models range from system-wide interventions to unit-based practice models. Further, fourteen of the twenty proposals indicated that patient outcomes would be measured in order to assess the impact of the models. These projects are likely to produce some interesting findings with regard to patient outcomes by 1994.

Another project with plans to collect patient outcome data is the New Jersey Nursing Incentive Reimbursement Awards (NIRA) Program (Knickman et al., 1991). This project is evaluating nursing innovations in 23 New Jersey hospitals. The innovations include redesigned work environments, including case management models; shared governance structures; computerized nursing process; and educational programs to address nurse satisfaction. The pre-test/post-test evaluation (with comparison units, as possible) will include the Hinshaw and Atwood (1982) patient satisfaction instrument and three indicators of quality of care: nosocomial infections, medication errors, and falls. The final report on this project is planned for June, 1992.

Other current projects include studies of practice models in specialty units, such as dedicated AIDS units, special care units for chronically critically ill patients (Daly et al., 1991), pediatric critical care units (Murphy, Walts, and Cavouras, 1989), and intensive care units (Phillips et al., 1990).

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