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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
Coordinating Care Delivery Models 10
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
Coordinating Care Delivery Models 11
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
Coordinating Care Delivery Models 12
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.
Coordinating Care Delivery Models 13
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,
Coordinating Care Delivery Models 14
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
Coordinating Care Delivery Models 15
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
Coordinating Care Delivery Models 16
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)
Relevant Health Care Background
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).
Evolution of Nursing
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
Coordinating Care Delivery Models 17
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
Coordinating Care Delivery Models 18
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
Coordinating Care Delivery Models 19
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
Coordinating Care Delivery Models 20
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
Coordinating Care Delivery Models 21
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)
Relevant Health Care Background
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
Coordinating Care Delivery Models 22
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
Coordinating Care Delivery Models 23
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.
Evolution of Nursing
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
Coordinating Care Delivery Models 24
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
Coordinating Care Delivery Models 25
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,
Coordinating Care Delivery Models 26
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
Coordinating Care Delivery Models 27
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
Coordinating Care Delivery Models 28
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
Coordinating Care Delivery Models 29
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).
Coordinating Care Delivery Models 30
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
Coordinating Care Delivery Models 31
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
Coordinating Care Delivery Models 32
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.
Coordinating Care Delivery Models 33
Primary Nursing (Late 1960s through the 1970s)
Relevant Health Care Background
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
Coordinating Care Delivery Models 34
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
Coordinating Care Delivery Models 35
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.
Evolution of Nursing
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.
Coordinating Care Delivery Models 36
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
Coordinating Care Delivery Models 37
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
Coordinating Care Delivery Models 38
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
Coordinating Care Delivery Models 39
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
Coordinating Care Delivery Models 40
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
Coordinating Care Delivery Models 41
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.
Coordinating Care Delivery Models 42
Practice Models Impacting on Nursing Care Delivery Systems (1980s)
Relevant Health Care Background
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
Coordinating Care Delivery Models 43
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
Coordinating Care Delivery Models 44
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,
Coordinating Care Delivery Models 45
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
Coordinating Care Delivery Models 46
(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
Coordinating Care Delivery Models 47
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.
Evolution of Nursing
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
Coordinating Care Delivery Models 48
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
Coordinating Care Delivery Models 49
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.
Coordinating Care Delivery Models 50
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
Coordinating Care Delivery Models 51
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
Coordinating Care Delivery Models 52
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.”
Coordinating Care Delivery Models 53
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
Coordinating Care Delivery Models 54
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
Coordinating Care Delivery Models 55
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
Coordinating Care Delivery Models 56
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
Coordinating Care Delivery Models 57
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
Coordinating Care Delivery Models 58
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
Coordinating Care Delivery Models 59
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
Coordinating Care Delivery Models 60
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)
Relevant Health Care Background
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
Coordinating Care Delivery Models 61
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).
Coordinating Care Delivery Models 62
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
Coordinating Care Delivery Models 63
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,
Coordinating Care Delivery Models 64
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).
Coordinating Care Delivery Models 65
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
Coordinating Care Delivery Models 66
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,
Coordinating Care Delivery Models 67
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
Coordinating Care Delivery Models 68
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
Coordinating Care Delivery Models 69
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.
Coordinating Care Delivery Models 70
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.
Evolution of Nursing
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.
Coordinating Care Delivery Models 71
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
Coordinating Care Delivery Models 72
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
Coordinating Care Delivery Models 73
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
Coordinating Care Delivery Models 74
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
Coordinating Care Delivery Models 75
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
Coordinating Care Delivery Models 76
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
Coordinating Care Delivery Models 77
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
Coordinating Care Delivery Models 78
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
Coordinating Care Delivery Models 79
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.
Coordinating Care Delivery Models 80
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
Coordinating Care Delivery Models 81
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
Coordinating Care Delivery Models 82
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)
Relevant Health Care Background
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
Coordinating Care Delivery Models 83
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,
Coordinating Care Delivery Models 84
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.
Evolution of Nursing
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
Coordinating Care Delivery Models 85
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
Coordinating Care Delivery Models 86
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
Coordinating Care Delivery Models 87
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
Coordinating Care Delivery Models 88
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,
Coordinating Care Delivery Models 89
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.
Coordinating Care Delivery Models 90
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
Coordinating Care Delivery Models 91
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
Coordinating Care Delivery Models 92
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
Coordinating Care Delivery Models 93
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
Coordinating Care Delivery Models 94
“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
Coordinating Care Delivery Models 95
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
Coordinating Care Delivery Models 96
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.
Coordinating Care Delivery Models 97
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
Coordinating Care Delivery Models 98
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
Coordinating Care Delivery Models 99
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
Coordinating Care Delivery Models 100
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
Coordinating Care Delivery Models 101
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.