The proofs for this edition reached me as I started updating my graduate course on the theories for healthcare practice. Offered every fall, the course is primarily concerned with theories of nursing, but extends to consider other theoretical frameworks relevant to patient care.
On downloading the proofs, my attention was drawn to the title of the first article 'Models of care in nursing: a systematic review' contributed by Dr. Fernandez and her colleagues.1 This article caught my eye because I thought it was going to be relevant to my course. That is, I imagined, wrongly, that the article was about evidence for or against the impact of nursing knowledge on patient outcomes, or at least on other outcomes relevant to healthcare; for example, nurse satisfaction or cost reduction. After reading the article my disappointment was less, but still substantial.
As you will read, Dr. Fernandez and her colleagues have reviewed the best available, if limited, evidence on the outcomes associated with what has become a popular way of organising nursing care. As it turns out, team nursing results in, or should I say is associated with a, 'significantly decreased incidence of medication errors and adverse intravenous outcomes as well as lower pain scores; 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 the incidence of pressure areas or infection rates. There was no significant difference in nursing outcomes relating to role clarity, job satisfaction and nurse absenteeism rates between any of the models of care.' (p. 324). Only 14 studies of the 3000 retrieved were of sufficient quality to be reviewed.
After reviewing the selected studies, Fernandez and her colleagues inform us tentatively that 'team nursing' may present a better model of care delivery for inexperienced staff to develop, especially in those units in which skill mix or experience is diverse. We are informed as well that despite its popularity, we would be mistaken to believe that there is evidence that team nursing results in superior healthcare outcomes. Furthermore, within primary nursing comparison studies, there is evidence of little benefit and cost-effectiveness.
The explanation for these findings may be found in the factors that have led to changes in the organisation of nursing work. As Fernandez and her colleagues point out, the healthcare environment in Western countries has undergone necessary changes due to budgetary constraints and shortfalls in the nurse workforce. These two influences are, of course, related. Women and men may have become more reluctant to become nurses except at times of high structural unemployment, which, predictably, is exactly when budgetary constraints place tough restrictions on hiring nurses, often as the first measure adopted in response to the challenge of trying to control, or at least slow down, the rising costs of healthcare. The substitution of enrolled nurses for registered nurses, and of healthcare assistants for both registered and enrolled nurses, dilutes the expertise available in the nurse workforce. The response of healthcare organisations is to introduce, by whatever name, care delivery systems within the capability of the resulting diverse workforce.
However, we should be cautious about assuming team nursing is a sufficient response to the inability of healthcare organisations to recruit and retain an all registered nurse workforce. As Fernandez and her colleagues reveal, the available evidence is severely limited, somewhat equivocal, and at best tentative. Perhaps, team nursing, however designated, cannot compensate for the inescapable dilution in nursing capacity caused by substituting less qualified and less experienced staff for registered nurses, unless we overlook the fact that all registered nurse workforces are not the same. Some settings, for example, have a higher proportion of university graduates; some settings have patients of higher acuity; some settings fully utilise the expertise of advanced clinical nurses. Such details could confound future systematic reviews of the outcomes of team nursing compared with those of an all registered nurse workforce. It would be one thing if the evidence showed that the outcomes of team nursing are no better than those achieved in settings where there is an all registered nurse workforce, but quite another if this was to hold true only for settings in which there are few or no clinical nurse leaders, clinical nurse specialists and nurse practitioners.
Perhaps the explanation for the equivocal results reported by Fernandez and her colleagues can be found in models of practice that have less to do with how healthcare delivery is organised and more to do with how it is conceptualised. The relevant missing factor may turn out to be that of understanding how knowledge and ethical commitments guide healthcare delivery. Authors of systematic reviews can only review studies of sufficient quality. Accordingly, it is no fault of Dr. Fernandez and her colleagues that the studies they have reviewed cannot furnish answers to pressing questions.
I should like to know what knowledge and ethical commitments guide everyday practice, and whether patient outcomes vary systematically with nurse preparation, clinical governance structures, whether nurses are budget holders and whether a chief nurse or equivalent has a seat at the table of corporate decision making. Such questions puzzle me because I cannot see that any model for delivering nursing care can be optimal unless the nursing team, however diverse, shares a professional model of care consistent with a higher ethical purpose, the best available evidence, and the resources to deliver the best of what the nurses of the 21st century know they can provide. But perhaps I conflate what is missing in the studies reviewed by Dr. Fernandez and her colleagues with the content of my graduate seminars.
1Division of Master of Nursing Science Program, Rafic Hariri School of Nursing, Faculty of Medicine, American University of Beirut, Beirut, Lebanon
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