The design for change in nursing practice as espoused in this research presentation adopts the PICO model toward understanding the basis for change. Precisely, relative references would be made to primary nursing on hospital units; mandated nurse ratios adherence; team nursing on hospital units with an expected outcome of providing safer, more efficient patient care with less stress to nursing service.
Evidenced based solution
This is derived from the protocol integration that, models of organising care range from those based on task allocation (e.g. functional nursing), through patient-allocation models (e.g. primary nursing), to team-organised models (team nursing).
In practice, such models are influenced by factors such as prevailing social values, management principles and cost-efficiency considerations (Tiedeman & Lookinland, 2004; Fairbrother, Jones & Rivas 2010) and may thus differ from the core models (functional, team and primary) envisaged in theory (e.g. modular nursing exemplified in Makinen, Kivimak, Elovainio, Virtanen & Bond, 2003).
Former studies compared wards with three types of nursing models: primary, team and a hybrid of primary and team nursing. Although the quality ratings did not differ significantly among the models, consideration of local ward conditions indicated that primary nursing to reduce the variance of care at ward level by as much as 32 per cent, a reduction not noted in other models (Sjetne et al. 2009, p.330).
Therefore, the actual solution lies in attempts at integrating primary and team nursing to ultimately enhance care. While this may be the desired outcome for change there have not been diverse studies about hybrid models to show where it was implemented and evaluated thoroughly to test its true efficacy. Theoretically, it has been argued that primary nursing is more advantageous to outcome than team.
The truth is that both have their place in nursing practice and function to effectively resolve workload issues and staffing frustrations on clinical areas. Primary is a more contemporary pattern of care supporting evidence- based nursing practice its truest sense. Its intervention centres upon the right nurse for the right patient at the right time. (Douglas, 2009).
However, in relation to this design for change in nursing practice a primary concept of care would be coordinated within a team typology utilizing the same leader concept of the team model, should quality of care be a major concern.
The practice environments for this proposed change are three medical units within a hospital setting. These have been selected because it would be necessary to test the effectiveness of a hybrid team/primary nursing versus team alone and primary only among similar patient populations.
Required resources include 30 patients per unit; 6 staff nurses per shift- two for each unit; 6 Licensed Practical Nurses (LPN) per shift – two per unit and 6 Certified Nursing Assistants ( CNA) per shift – two per unit. The nurse /patient ratio would, therefore, be 5:1.
Charts evaluating change will be utilized for documenting tasks and outcomes during a period of six months. Equipment for administering daily care will also be added to the inventory list of resources needed, but may not be directly related to the change because they have already been designated as part of any nursing intervention.
Staff will be trained prior to the execution of this project.2 -staff nurses; 2- LPNs and 2 - CNA’s will be allocated per shift in each unit containing 30 patients with medical conditions, which do not require any intensive care intervention. Staff nurses will be responsible for allocating tasks based on the level of care required per patient and the licensed designation of nursing service staff involved.
The hybrid program will be evaluated in terms of quality of care and less stressful intervention in comparison to primary and team nursing being executed on two other wards. Staff nurses will lead the nursing care intervention. One allocates tasks and the other merely supervises intervention ensuring that they are carried out according to protocol.
As such, two staff nurses are responsible for ward management when it comes to delivery of patient care and a combination of 4 LPNs and CNAs are expected to administer such care except in situations when it contraindicates their nursing role and designation. Subsequently, they are allocated 7-8 patients per shift to complete tasks.
At the end of each shift a record of tasks completed will be submitted to two ward supervisors (RNs) who will evaluate the outcome executed by LPNs and CNAs. Each month repots will be compiled for six consecutive months to assess the outcome of the program.
Expected outcomes and tools for measurement
The obvious expected outcome is indicative of providing safer, more efficient patient care with less stress to nursing service. However, in this study it means much more than just that. Tools used were suffessful tasks completion ratings , which indicates whether LPNs and CNAs have the required training to execute tasks efficiently for which they were assigned.
The second tool related to the question is, are Staff Nurses effective team leaders in the execution process of nursing intervention? Can they lead from behind and empower subordinate staff to function at their best at all times to eventually produce safer, more efficient patient care with less stress to nursing service, which is the ultimate goal.
Another major expected result insidious to this study, is implicitly learning the appropriate applicability of nurse- patient ratio in either situations be it the hybrid model, primary or team management typology by measuring favorable outcomes. This is the third tool employed . In nursing service administration this has been a grave concern overtime.
Douglas, K, (2009), "The naked truth: staffing in health care needs an
Overhaul", Nursing Economics, 27( 9).332-334