Agreement was reached with 12 acute medical and surgical wards/units at Sydney's Prince of Wales Hospital to participate in a trial of team nursing (TN). Six units employed action research principles to undertake a change to a team nursing model and six remained with the pre-existing individual patient allocation (IPA) model. Task-based teaming was widely discarded by the team nursing units in favour of allocating patients within the team and introducing more supportive and communicative processes aimed at fostering responsibility sharing. Localised team-based models of care arose in the change wards and were outlined, implemented and refined using social action research principles. A 12-month prospective experimental comparison of job satisfaction and staff retention between the TN and IPA groups indicated statistically significant job satisfaction benefits and practically important staff retention benefits associated with moving away from an IPA model of nursing care delivery towards a team-based model of care delivery. Perhaps not surprisingly, job satisfaction gains were most marked among new graduate nurses, who reported real benefits from a teaming inspired shift in model of care in the acute inpatient environment.
KEYWORDS: models of care; nursing; acute care; team nursing; nursing models; job satisfaction; nurse retention
A fresh emphasis on care modeling commenced in acute nursing perhaps a decade ago. Recent interest in nursing models of care has in many respects been driven by workforce concerns. Chronic shortage of experienced and novice staff (Satterly, 2004) and workplace retention problems (Bartram, Joiner, & Stanton, 2004) have plagued nursing's professional growth around the world for much of this decade.
Models of care were required for the many advanced practice roles which began to develop and consolidate in acute and critical care (Kleinpell et al., 2002) and chronic and community care settings (Eaton, 2000). In addition, the increasing trend in favour of stratifying skillmix and using unlicensed assistive personnel required the development of a focus on daily work patterns (Anthony, Standing, & Hertz, 2001).
In response to these and other pressures of fiscal, demographic, social and technological character (Parliament of Australia, 2002), nursing thought has in recent years departed from an earlier overemphasis on theory generation (C. Taylor, 1998), to concern itself firstly with developing a credible evidence base for clinical practice (Gerrish, 2004) and secondly, with understanding and developing the workings of the workplace itself.
Organising daily nursing work in the acute ward essentially remains a choice between: (i) patient allocation, total patient care or primary nursing models; (ii) task allocation or functional models; or (iii) team nursing models. Primary nursing arose under Nightingale and was the main care delivery model in much of the western world until the 1930s (Tiedeman & Lookinland, 2004). It made a resurgence with nursing's move to academic undergraduate preparation in the 1970s-1980s. In its modern manifestation as individual patient allocation (IPA), it remains the principal model of care employed in Australian acute hospitals today. In this model, one nurse assumes responsibility for the complete care of a group of patients on a one to one basis, providing total patient care during the shift. Unlike primary nursing (which inspired it), IPA requires no one person to be responsible for the ongoing coordination of the care given throughout the patient's hospital stay.
The functional model of care emerged during World War Two. An increase in nurses was needed at this time and the functional model was initiated in response to the need for less skilled ancillary personnel and also the generalised expansion of hospital systems. Work was divided into tasks in this model. Tasks were assigned to nursing and ancillary personnel based on the complexity of the task in terms of judgment and technical knowledge. …