Authors

1. King, Allana RGN, BNurs, MHIthAdmin, CFJBI, Master of Clinical Science candidate
2. Long, Lesley AM PhD, MHA, Ba Nsg, RGN
3. Lisy, Karolina BSc (Hons) PhD, Research Fellow

Abstract

Review question/objective: The objective of this systematic review is to critically appraise and synthesize the best available evidence on the effectiveness of team nursing compared to total patient care on staff wellbeing when organizing nursing work in acute care ward settings. This review will seek to answer the following question:

Is a team nursing or a total patient care approach the most effective model of care when organizing nursing work to achieve desired staff wellbeing (defined by outcomes of staff satisfaction, stress, burnout, absenteeism and turnover) in a general ward setting?

Background: The organization of work for nurses according to recognized models of care can have a significant impact on the wellbeing and performance of nurses and nursing teams. Model of care as described by Fowler, Hardy and Howarth 2006 will be the definition utilized for this review:

Provision of care in an organisational setting, specifically at a clinical services unit level (ward)[horizontal ellipsis]Presents the structural and contextual dimensions of nursing practice[horizontal ellipsis]Governs the manner in which nurses organise work groups, communicate with work group members and with other disciplines, interact, make decisions, and create an environment within which nursing care is delivered among care providers, and specify communication and coordination patterns necessary to support care.1^{(pp. 40-41)}

There are four predominant traditional nursing care models described in the literature to organize nursing work: team nursing, total patient care (also known as patient allocation), task method, and primary nursing.2 In recent years, other models as well as various combinations of different models have emerged. In Australia, individual total patient care is the main model utilized in acute care hospitals.3 Team nursing is also a prominent care delivery model used in general ward settings whereas task allocation and primary nursing is not as commonly utilized. The model of nursing selected is dependent on nursing resources and patient care requirements. Tiedeman and Lookinland 2004, state that models "differ in clinical decision making, work allocation, communication, and management, with differing social and economic forces driving the choice of model."4^{(p 291)}

As team nursing and total patient care are the two most common models utilized in Australia,5 these are the two models of interest to this review. The team nursing model of care involves a group of nurses who work as a team to deliver the care. This model utilizes the diversity of skill, education and qualification level of each team member. The team works collaboratively with shared responsibility.3 This model usually relies on a team leader who is a registered nurse. It is important that the team leader has effective communication and leadership skills.6 The total patient care model consists of one nurse who is allocated to a group of patients for that shift; however continuity of care is not followed through from admission to discharge as the patients are allocated on a shift-by-shift basis.2,3 Registered nurses (RN) or enrolled nurses (EN) may be allocated to total patient care, but an RN would usually oversee the care. The first report on the models of care project by the New South Wales Department of Health discusses that total patient care is the main model utilized since nursing moved to the tertiary sector in Australia and that many graduates have only been educated in total patient care.7

In Australia and internationally, the nursing workforce has changed considerably due to multifactorial influences such as budgetary constraints, hospital restructuring, an ageing workforce, advanced practice roles for registered and enrolled nurses, changes in scope of practice, skill mix and the introduction of undergraduate nurses, recruitment and retention of staff, and increases in complexity of care.8,9 The model of care chosen to organize nursing work needs to accommodate all of these influences. The model of care delivery and the effects on patient care have been discussed in the literature and it has been found that care models with a greater registered nurse skill mix have been linked to improved outcomes such as lower patient mortality and wound infections, and a reduction in medication errors.10 The focus of this review is on the model of nursing care delivery by one of two particular models: team and total patient care, and the effect that these care models have on nurses' wellbeing. The reviewer acknowledges the importance of measuring patient clinical outcomes and organizational factors to inform the delivery of safe and cost effective clinical care, however, these outcomes will be excluded from the review as there have been previous reviews to inform practice in this area.11-13

The model of care is critical in defining the nursing work environment. Nursing work environments are complex; prioritizing work is essential and the need to reprioritize nursing workloads on a daily basis is often necessary. Research has shown that nursing work environments and also job satisfaction are influenced by organizational structures, leadership, autonomy, models of care, multidisciplinary collaboration and interpersonal relationships.5,14 Ward areas may adapt different models of care due to the knowledge and skill level of staff or to influence teamwork to increase job satisfaction. Organizations need to manage within allocated resources and ensure that they have the most appropriate model to support staff and ensure safe effective clinical outcomes. Regardless of the model of care, all nursing staff are required to practice within their scope of practice and be aware of the scope of their colleagues' practice. Confusion surrounding scope of practice leads to conflict, inter-professional rivalry, and even bullying.15 Due to the global shortage of nurses and skill mix issues it is important to ensure the organizational model in the clinical area utilizes the skills and experience of the available staff.

Workplace stress and burnout have implications for both the employee and the organization regardless of the workplace. Jennings 2008 citing Lazarus 2004, described stress as a "relationship between the person and the environment that is appraised by the person as taxing or exceeding his or her resources and endangering his or her wellbeing."16^{(p NP)} If high stress levels are maintained this could result in burnout. Burnout can be defined as physical or mental collapse caused by overwork or stress.17 In terms of nursing, stress and burnout can have long standing implications for the nurse on health and job satisfaction and for the employer it can influence turnover and absenteeism.16

The purpose of this review will be to compare the effectiveness of team nursing and total patient care through evaluating which model of care achieves greater staff wellbeing. Staff wellbeing will be measured by staff outcomes in relation to staff satisfaction, turnover, absenteeism, stress levels and burnout. This review will focus on the acute care hospital sector and in particular general ward settings. To avoid potential duplication of the proposed review topic, searches of the Joanna Briggs Institute Library and The Cochrane Library were undertaken. The search identified a systematic that looked at various models of care and the effects these models have on staff and patient outcomes. Staff outcomes included staff satisfaction, role clarity and absenteeism. The review also looked at patient outcomes in terms of nurse sensitive indicators such as falls, medication errors and infection rates. However, the proposed review, while replicating some of the outcome measures used in a review by Fernandez et al 2012, extends the outcomes to include turnover, stress and burnout and narrows the focus to two models of care delivery. The purpose of replicating some of the outcome measures of staff satisfaction and absenteeism is to extract a clear picture of the differences in the two care models: team nursing and total patient care. There have been quantitative and qualitative reviews conducted on nursing models and the effects on patient, organizational and staff related outcomes11-13 but none narrowing the focus to these two models and their direct effect on staff wellbeing.

It is envisaged that this quantitative review will assist in informing practice on these two care delivery models: team nursing and total patient care, by establishing the effect that each model has on the nurses delivering them. This review seeks to enable a greater understanding of the impact stress and burnout, turnover rates, absenteeism and staff satisfaction have on staff wellbeing. In Australia, the Australian Nursing and Midwifery Council outlines that nurses' scope of practice encompasses activities such as decision making, role and responsibility, and function, and the scope of practice which is legislated.18 The role of the registered nurse includes delegation and this requires an understanding of other team member's scope of practice, education level and experience. The review authors are interested in the topic at a local level as currently in Australia there are a number of new hospitals being constructed or under redevelopment and this review may assist in informing practice on the preferred model of care. The review will also be looking at the impact of team and total patient care from a global perspective on staff wellbeing to ensure best available studies which meet the criteria are included in the review.