Academic journal article Contemporary Nurse : a Journal for the Australian Nursing Profession

Changing Model of Nursing Care from Individual Patient Allocation to Team Nursing in the Acute Inpatient Environment

Academic journal article Contemporary Nurse : a Journal for the Australian Nursing Profession

Changing Model of Nursing Care from Individual Patient Allocation to Team Nursing in the Acute Inpatient Environment

Article excerpt


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. Lessskilled workers were assigned most of the routine tasks, and the Registered Nurse addressed the more complex needs. Functional nursing depends on both rules and rituals. It can be seen to be a direct descendant of the industrial massproduction ideas about work allocation which were prevalent at the time, as a task specialization and assembly-line approach had proven massively successful in industry (Dingwall, Rafferty, & Webster, 1988).

Team nursing (TN) emerged in the 1950s as a response or reaction to functional nursing. The model used a group of nurses with diversity in education, skills and professional registration status. The focus was to work collaboratively and cooperatively with shared responsibility, and to some extent accountability. The time span of patient-team assignment varied from a shift to permanent team allocation for the duration of the patient's hospital stay. The 1960s and 1970s were the golden age of team nursing. Applying humanistic values in the workplace became increasingly important during this period (Tiedeman & Lookinland, 2004) and the team approach seemed to account for the whole patient (as primary nursing had done) within the context of a multi-level skill mix and responsibility mix environment.

TN was superseded by IPA in the 1970s and 1980s as nursing sought to manifest its newly emerging faculty based professional stance in a practice model which promoted full professional accountability (Ethridge & Lamb, 1989). …

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