Master of Clinical Science

The effectiveness of a team nursing model compared with a total patient care model
on staff wellbeing when organizing nursing work in acute care wards

Allana King RGN, BNurs, MHlthAdmin, CFJBI, MSc candidate

Student number a1642063
Joanna Briggs Institute
Faculty of Health Sciences
The University of Adelaide
[email protected]

Date: July 2016

The effectiveness of a team nursing model compared with a total patient care model
on staff wellbeing when organizing nursing work in acute care wards

Allana King RGN, BNurs, MHlthAdmin, CFJBI, MSc candidate

Clinical Service Coordinator, Royal Adelaide Hospital and Masters of Clinical Sciences Candidate,
Joanna Briggs Institute, Faculty of Health Sciences, The University of Adelaide.
[email protected]

Supervisors:

A/Prof Lesley Long, AM PhD, MHA, Ba Nsg, RGN

Joanna Briggs Institute, Faculty of Health Sciences,
The University of Adelaide, South Australia 5005
[email protected]

Dr Karolina Lisy BSc (Hons) PhD, Research Fellow

Joanna Briggs Institute, Faculty of Health Sciences,
The University of Adelaide, South Australia 5005
[email protected]

Page 2
Declaration

I, Allana King, certify that this work contains no material which has been accepted for the award of any
other degree or diploma in any university or other tertiary institution, and to the best of my knowledge and
belief, contains no material previously published or written by another person, except where due
reference has been made in the text.

I give consent to this copy of my thesis, when deposited in the University Library, being made available for
loan and photocopying, subject to the provisions of the Copyright Act 1968.

I also give permission for the digital version of my thesis to be made available on the web, via the
University’s digital research repository, the library catalogue and also through web search engines, unless
permission has been granted by the University to restrict access for a period of time.

Allana King

Dated: 31/7/2016

Page 3
Table of Contents
Declaration ................................................................................................................................... 3
Table of figures and tables ............................................................................................................. 7
Abstract ................................................................................................................................... 8
Acknowledgements....................................................................................................................... 11
List of Abbreviations ..................................................................................................................... 12
Chapter 1 Introduction 14
1.1 Introduction and structure of the thesis .............................................................................. 14
1.2 Nursing Theorists ............................................................................................................... 14
1.3 Context of the review ......................................................................................................... 16
1.3.1 Team nursing model......................................................................................................... 17
1.3.2 Total patient care model ................................................................................................... 17
1.3.3 Task nursing model .......................................................................................................... 17
1.3.4 Primary nursing model ..................................................................................................... 17
1.3.5 Skill mix ....................................................................................................................... 19
1.3.6 Re-designing nursing work ............................................................................................... 19
1.3.7 Scope of practice ............................................................................................................. 19
1.3.8 Job satisfaction ................................................................................................................ 20
1.3.9 Stress and burnout ........................................................................................................... 20
1.3.10 Absenteeism .................................................................................................................... 20
1.3.11 Turnover ....................................................................................................................... 21
1.4 Introduction to systematic reviews ..................................................................................... 21
1.4.1 Characteristics of a systematic review ............................................................................. 21
1.4.2 Types of systematic reviews ............................................................................................ 22
1.5 Science of statistical synthesis .......................................................................................... 24
1.6 History of research methodology paradigms ...................................................................... 24
1.7 Narrative synthesis ............................................................................................................ 25
1.8 Evidence-Based Practice (EBP) ........................................................................................ 25
1.9 Why undertake a systematic review................................................................................... 27
1.10 Statement of the review question ....................................................................................... 28
1.11 Defining the terms .............................................................................................................. 28
Chapter 2 Methods 29
2.1 Review question and objectives ......................................................................................... 29
2.2 Inclusion criteria ................................................................................................................. 29
2.2.1 Types of studies ............................................................................................................... 29
2.2.2 Types of participants ........................................................................................................ 29
2.2.3 Type of intervention and comparator ................................................................................ 30
Page 4
 2.2.4 Types of outcomes ........................................................................................................... 30
2.3 Search Strategy ................................................................................................................. 30
2.4 Assessment of methodological quality ............................................................................... 31
2.4.1 Data collection .................................................................................................................. 31
2.4.2 Data synthesis.................................................................................................................. 31
Chapter 3 Results 32
3.1 Search and study selection ................................................................................................ 32
3.2 Methodological quality ....................................................................................................... 34
3.3 Description of included studies .......................................................................................... 35
3.4 Results: Outcome measures.............................................................................................. 37
3.4.1 Job satisfaction ................................................................................................................ 37
3.4.2 Stress ....................................................................................................................... 40
3.4.3 Burnout ....................................................................................................................... 41
3.4.4 Absenteeism .................................................................................................................... 41
3.4.5 Staff turnover.................................................................................................................... 41
Chapter 4 Discussion and Conclusions 43
4.1 Discussion ......................................................................................................................... 43
4.1.1 Nursing Models and Staff Wellbeing ................................................................................ 43
4.1.2 Nursing Models and Patient Care..................................................................................... 46
4.1.3 Terminology and Methodological Tools ............................................................................ 47
4.1.4 Restructuring and ward design ......................................................................................... 48
4.1.5 Cost effective care............................................................................................................ 49
4.1.6 Professional practice models and Magnet® ..................................................................... 49
4.1.7 Nursing leadership ........................................................................................................... 50
4.2 Limitations of the review .................................................................................................... 51
4.3 Conclusion ......................................................................................................................... 52
4.4 Implications for practice ..................................................................................................... 52
4.5 Implications for research .................................................................................................... 53
References 54
Appendix I: Systematic review protocol ............................................................................ 62
Appendix II: Search strategy.............................................................................................. 72
Appendix III: Appraisal instrument ...................................................................................... 75
Appendix IV: Data Extraction Instruments........................................................................... 76
Appendix V: Characteristics of included studies ................................................................ 78
Appendix VI: List of excluded studies.................................................................................. 81
Appendix VII: Studies included in review ............................................................................. 85
Appendix VIII: Editorial .......................................................................................................... 86
Page 5
Appendix IX: JBI Grades of Recommendation .................................................................... 89

Page 6
Table of figures and tables

Figure 1 - Study identification process .......................................................................................... 33

Table 1 - Methodological quality of included studies ................................................................... 34

Table 2- Models of care as described in included studies and in alignment with
terminology in review .................................................................................................... 35
Table 3 - Job satisfaction ............................................................................................................ 37
Table 4 - Stress ........................................................................................................................... 40
Table 5 - Staff turnover................................................................................................................ 42

Page 7
Abstract

Background

The organization of the work of nurses, according to recognized models of care, can have a significant
impact on the wellbeing and performance of nurses and nursing teams. This thesis focuses on two models
of nursing care delivery, namely, team and total patient care, and their effect on nurses’ wellbeing.

Objectives
To examine the effectiveness of a team nursing model compared with a total patient care model on staff
wellbeing when organizing nursing work in acute care wards.

Inclusion criteria
Types of participants
Participants were nurses working on wards in acute care hospitals.

Types of intervention
The intervention was the use of a team nursing model when organizing nursing work. The comparator was
the use of a total patient care model.

Types of studies
This review considered quantitative study designs for inclusion in the review.

Types of outcomes
The outcome of interest was staff wellbeing which was measured by staff outcomes in relation to job
satisfaction, turnover, absenteeism, stress levels and burnout.

Search strategy
The search strategy aimed to find both published and unpublished studies from 1995 to April 21, 2014.

Methodological quality
Quantitative papers selected for retrieval were assessed by two independent reviewers for
methodological validity prior to inclusion in the review using standardized critical appraisal instruments
from the Joanna Briggs Institute.

Data collection

Page 8
Data was extracted from papers included in the review using the standardized data extraction tool from
the Joanna Briggs Institute. The data extracted included specific details about the interventions,
populations, study methods and outcomes of significance to the review question and its specific
objectives.

Data synthesis
Due to the heterogeneity of the included quantitative studies, meta-analysis was not possible thus results
have been presented in a narrative form.

Results
The database search returned 10,067 records. Forty-three full text titles were assessed, and of these 40
were excluded, resulting in three studies being included in the review. Two of the studies were quasi
experimental designs and the other was considered an uncontrolled before and after experimental study.
There were no statistically significant differences observed in any study in the overall job satisfaction of
nurses using a team nursing model compared with a total patient care model. Some differences in job
satisfaction were however observed within different subgroups of nurses. There were no statistically
significant differences in either stress or job tension. Within the selected studies, the specific outcomes of
absenteeism and burnout were not addressed.

Conclusions
Due to the limited number of quantitative studies identified for inclusion it was not possible to determine
whether organizing nursing work in a team nursing model or a total patient care model is more effective in
terms of staff wellbeing. Neither a team nursing model or a total patient care model had a significant
influence on nurses’ overall job satisfaction, stress levels or staff turnover. There is an inability to ascertain
if the type of model of care affects absenteeism or burnout as these outcomes were not addressed in any
of the identified studies.

Implications for practice

Caution should be taken when evaluating which model of care is appropriate and the decision needs to
incorporate staff experience levels and staff skill mix. There needs to be clear definition of nursing roles.

Implications for research

There is a need for further quantitative studies that are well designed with sufficient sample sizes to allow
for attrition of participants, and that explore the impact each model has on nurse’s wellbeing, in particular,
studies that address burnout and absenteeism. Consistent terminology is required to enable future
comparison and research to occur at an international level. Future studies on models of care should
Page 9
include economic analysis to fully inform policy and practice.

Keywords
Total patient care, patient allocation, team nursing, nursing model, nursing care delivery system, patient
care delivery system, job satisfaction, absenteeism, wellbeing, turnover, stress, burnout, sick leave,
nursing staff hospital, nurses, general ward and units.

Page 10
Acknowledgements

I would like to thank and acknowledge a number of significant people who without their support completion
of this thesis would not have been possible.
Firstly, I would like to thank my supervisors Associate Professor Lesley Long, my primary supervisor and
Dr Karolina Lisy, my secondary supervisor for their patience, advice, understanding, editing and
encouragement. I could not have completed this without you two and I am extremely grateful to you both.
I would also like to take this opportunity to thank all the staff and fellow students at the Joanna Briggs
Institute for all of their encouragement and assistance. Thank you to Maureen Bell, research librarian with
the Barr Smith Library, University of Adelaide, for her advice on searching databases

My partner, Chip, you are one of a kind. I love you and I am so grateful that we have each other. To my cat,
Sox, thank you for sitting up with me into the early hours of the morning and giving me a purr and cuddle
when needed. To my sister, Rae and her children, Claudia and Hamish, thanks for all the love and
diversions when needed and my friend’s thank you for all of your support and understanding, what a
journey it has been.

To my employer, direct line manager, Su thank you for providing flexibility and allowing me to undertake
this study. To my work colleagues and staff that I manage you have all inspired me to continue to question
what we do to ensure that we are providing the best evidence based care for our clients and patients.

Finally, I would like to dedicate this thesis to my dear mum, Marilyn who unfortunately passed away soon
after I commenced this study. Mum you encouraged me to always strive and achieve and was so
supportive in my nursing career and study, thank you for always being my guiding light, love and miss you.

Page 11
List of Abbreviations

AHRQ………………….Agency for Healthcare Research and Quality

AIN……………………..Assistant in Nursing
ANOVA………………...Analysis of Variance
CBA…………………….Cost Benefit Analysis
CEA…………………….Cost Effective Analysis
CI ………………………Confidence Interval
CMA……………………Cost Minimisation Analysis
CReMS……………. ….Comprehensive Review Management System
CUA…………………….Cost Utility Analysis
EBM…………………… Evidence-based Medicine
EN………………………Enrolled Nurse
EBP…………………….Evidence-based Practice
FTE……………………. Full Time Equivalent
JBI………………………Joanna Briggs Institute
JDI……………………...Job Descriptive Index
JIG……………………...Job in General
IPA……………………...Individual Patient Allocation
IWS……………………..Index of Work Satisfaction
PA………………………Patient Allocation
SUMARI………………..System for the Unified Management, Assessment and Review of Information
MAStARI……………….Meta-Analysis of Statistics Assessment and Review Instrument
NICE……………………National Institute for Healthcare Excellence
NWSQ………………….Nursing Workplace Satisfaction Questionnaire
QALY…………………. Quality Adjusted Life Years
RCT…………………….Randomized Controlled Trial
RN………………………Registered Nurse
ROS…………………….Range of Scores
SALSA…………………Search, Appraisal, Synthesis and Analysis
SCN…………………….Shared Care in Nursing
SD………………………Standard Deviation
Page 12
SIG……………………..Stress in General
TN………………….......Team Nursing
TPC…………………….Total Patient Care

Page 13
Chapter 1 Introduction

1.1 Introduction and structure of the thesis

This thesis is titled the effectiveness of a team nursing model compared with a total patient care model on
staff wellbeing when organizing nursing work in acute care wards. This thesis consists of four chapters.
Chapter one is an introduction to the research topic and discusses the context and need for a review, to
investigate two particular nursing models of care and their impact on nurses’ wellbeing. This chapter also
describes systematic reviews and the importance systematic reviews have on healthcare. Chapter two
presents the systematic review method which the thesis has been developed from, and includes the
review objectives, types of studies, the inclusion criteria and search strategy. One of the requirements of a
Joanna Briggs Institute (JBI) systematic review is the publication of an a priori protocol, which outlines the
methods. Performed protocol was developed and published in the JBI Database of Systematic Reviews
and Implementation Reports 1 and in the international database of prospectively registered systematic
reviews in health and social care PROSPERO, registration number CRD42014008768.2 (Appendix I)

Chapter three presents the results of the systematic review, as published in the JBI Database of
Systematic Reviews and Implementation Reports.3 This chapter includes the identified studies, their
methodological quality, results as to the effectiveness of a team nursing model compared to a total patient
care model on nurses’ wellbeing and a synthesis of the findings. Chapter four constitutes the discussion,
conclusions, implications for practice and further research in the area of nursing models and their effect on
staff wellbeing when organizing nursing work in acute care wards. This thesis also includes references,
acknowledgements and appendices.

1.2 Nursing Theorists

This thesis is focused on nursing care delivery models to organize nursing work. It has become apparent
that the term ‘model of care’ can be confusing due to the way it is often poorly defined and varying ideas
as to what it entails, from governance structure to the allocating of patients to nurses.4

A significant finding from this thesis has been there is extensive literature on models of care despite this
there is a lack of theory or frameworks which incorporate the complexities of nursing care organization
and this has resulted in a disjointed understanding of organizational models.5 Consistent and agreed
terminology is required for future studies to ensure differentiation can occur between the various nursing
care delivery models to enable comparison between studies.

This thesis is not about professional nursing practice frameworks or theories per se, but how models of
care are structured and delivered and their impact on nurses’ wellbeing. It is however necessary to have
an understanding of how nursing care delivery models have been developed and influenced by theorist
Page 14
and practice models throughout history. The term model, is widely used, and is often used in nursing to
describe theories,6 which has contributed to difficulties in distinguishing between the two. There have
been various philosophies and theorists in nursing; as McCrae 2012 states, “the legitimacy of any
profession is built on its ability to generate and apply theory. While enjoying a cherished status in society,
nursing has struggled to assert itself as a profession.”7(p.222) Nursing has attempted for many years to
gain credibility in the medical field and has undertaken educational reform in an attempt to develop the
profession and bridge the gap between theory and practice.7

Alligood 2010 discusses, how nursing theory has been a focus for the past fifty years resulting in a broad
range of nurse theorists and a variety of theoretical works.8 This thesis will not address all of the models
and theories, it will provide a brief summary of some examples of theories that have shaped nursing over
time. Arguably the most prominent figure in nursing is Florence Nightingale, whose philosophy was that
there is a need to look into deeper causes of health and illness rather than the just the disease and who
has provided nursing with a scientific model to continue to build on.9

Other influential theorists that have driven the development of nursing as a profession includes, Virginia
Henderson, “known as the mother of modern nursing”6(p.24) developed 14 conditions based on the
following four criteria; physical, psychological, spiritual and sociological with the theory that the nurse
provides the care when these needs aren’t met.10 Hildegard Peplau’s postulated a theory was based on
the patient’s need for respect, dignity and the nurse needing to be aware of these needs, and she
describes three phases in the nurse patient relationship; orientation, working and termination. In phase 1
the nurse introduces and obtains information, phase 2 provides care, education and counselling and
phase 3 sees the patient discharged from care.6 The Neuman’s system model was developed in the
1970’s by Betty Neuman and views how stressors affect an individual in their environment and that these
can be intrapersonal, interpersonal and extrapersonal. 6 Dorothy Johnson’s Behavioral System Model
advocates the fostering of efficient and effective behavioral functioning based on subsystems, and the
nurse’s role is to restore balance.6

Further theorists have cemented concepts of care into fundamental aspects the profession, such as
Madeline Leininger, who’s cultural care theory is based on care and transculturality and its importance in
healing.11 Jean Watson’s, theory is based on human caring and contains 10 carative factors and 10
assumptions related to care, with the fundamental theory being that caring is the most important function
in nursing.6 There are many other theorists which will not be described in detail but they include nursing
theories such as Imogen King’s theory of goal attainment, Dorothy Orem’s self-care theory and the
dynamic nurse-patient relationship theory developed by Ida Orlando.11 The final theorist which needs to
be mentioned is Professor Patricia Benner who developed the ‘from novice to expert’ theory which
focuses on nurse’s clinical competence.12 These levels of experience consist of novice, advanced

Page 15
beginner, competent, proficient and expert with each phase of experience the nurse builds on their
knowledge and skill level and was adapted from the Dreyfus model of skill acquisition.13

The discussion of nursing theorists leads to practice models. Nursing uses terms such as patient care
delivery model, professional practice model, integrated delivery system and nursing professional practice
model interchangeably and many are often unsure of the definitions; nurses therefore find it difficult to
articulate their meaning.14 The elements of what constitutes a nursing model is described by Pearson et
al. 2005 as components and elements which describe what nursing is; the theories, concepts, beliefs,
values, goals, knowledge and skills required.15 Chamberlain et al. 2013, discuss that organizations
should select a nurse theory based on the vision and values of the organization.14 Due to the confusion
and interchangeable terminology, nursing staff will need education to ensure they have an understanding
of the theory and are able to define the “practice model and care delivery system that’s congruent with its
philosophy.”14(p.18).

In summary, this thesis acknowledges the difference in practice models and care delivery systems and
supports the idea that a care delivery system is influenced by the model of practice15 and is not a practice
model but a model of work organization. Practice models and frameworks will be explained further in the
discussion section of this thesis. The next section describes the context of the review and common
nursing care delivery models which organize nursing work, focusing in particular on a team nursing model
and a total patient care model and how these two models affect nursing wellbeing.

1.3 Context of the review

The organization of the work of nurses, according to recognized models of care, can have a significant
impact on the wellbeing and performance of nurses and nursing teams. A model of care as described by
Fowler, Hardy and Howarth, is the definition used for the review and thesis; they define model of care as
the:

“Provision of care in an organizational setting, specifically at a clinical services unit level (ward)…Presents
the structural and contextual dimensions of nursing practice...Governs the manner in which nurses
organize work groups, communicate with work group members and with other disciplines, interact, make
decisions, and create an environment within which nursing care is delivered among care providers, and
specify communication and coordination patterns necessary to support care.”4 (p.40-41)

There are four dominant traditional nursing care models described in the literature to organize nursing
work: team nursing, total patient care (also known as patient allocation), task method, and primary
nursing.16 These models are internationally recognized models of nursing care delivery and commonly
applied in acute care hospital settings to organize nursing work. In recent years there has been the
emergence of other models as well as various combinations of different models.

Page 16
Shields 2002 describes that nursing models assist in organizing nursing as a coherent whole and defines
what nurses do and how they do it.17

In Australia, individual total patient care is the main model used.18 Team nursing is also a prominent care
delivery model used in acute care ward settings whereas task allocation and primary nursing is not as
commonly used. The model of nursing selected is dependent on nursing resources and patient care
requirements. Tiedeman and Lookinland 2004 state that models “differ in clinical decision making, work
allocation, communication and management, with differing social and economic forces driving the choice
of model.”19(p291) As team nursing20 and total patient care are common models used in Australia,21 these
are the two models of interest in this review.

1.3.1 Team nursing model

The team nursing model of care is where a group of nurses work as a team to deliver the care. This model
utilizes the diversity of skills, and education and qualification levels of each team member. The team
works collaboratively with shared responsibility.18 This model usually relies on a team leader who is a
registered nurse. It is important that the team leader has effective communication and leadership skills. 22
The team leader needs an established skill set and must be able to supervise staff, as staff satisfaction is
linked to supervision.23

1.3.2 Total patient care model

The total patient care model is where one nurse is allocated a group of patients for that shift; however
continuity of care is not followed through from admission to discharge as the patients are allocated on a
shift-by-shift basis.16,18 Registered Nurses (RN), Enrolled Nurses (EN) or Assistants in Nursing (AINs)
may be allocated to total patient care, but an RN would usually oversee the care. The first report on the
models of care project by the New South Wales Department of Health discusses that total patient care is
the main model utilized since nursing moved to the tertiary sector in Australia and that many graduates
have only been educated in total patient care.21

1.3.3 Task nursing model

Task nursing allocation (also known as functional nursing) is defined by Thomas et al, (1990) in Pearson
et al.16 as the “division of nursing work into separate tasks, where tasks are allocated according to skill
level, while the nurse in charge retains responsibility and accountability for the totality of patient care.” 16(p.
14) This model of care has a hierarchical structure and relies on the nurse in charge to assign tasks
based on an individual’s level of education.24 Tiedeman and Lookinland 2004 describe that this model
of care was popular in the 1950’s and 1960’s and had been taken from the manufacturing industry as a
task specialization in an assembly line approach was seen as effective.19

1.3.4 Primary nursing model

Primary nursing involves the allocation of a patient to a nurse from the time of admission through to the

Page 17
time of discharge. “The primary nurse assumes 24-hour responsibility and accountability for assigned
patients for the duration of their hospital stay and has the responsibility and authority to assess, plan,
organize, implement, coordinate, and evaluate care in collaboration with the patients and their families.”
19(p 295) Further described by Sellick et al. 2003 as an organizational care model with the focus on
comprehensive, continuous, individualized care by the nurse who has the autonomy and authority to
implement that care.25

Nurses provide service delivery across all healthcare settings, therefore managers need to ensure that
the models of care delivery maximize this valuable resource as nurses are critical to the organizational
performance and in ensuring safe high quality care is delivered.5 In Australia and internationally, the
nursing workforce has changed considerably due to multifactorial influences such as budgetary
constraints, hospital restructuring, an aging workforce, advanced practice roles for registered and enrolled
nurses, changes in scope of practice, skill mix and introduction of undergraduate nurses, recruitment and
retention of staff and increases in complexity of care.26,27 The model of care chosen to organize nursing
work needs to accommodate all these influences. The model of care delivery and the effects on patient
care have been discussed in the literature and those models with a greater registered nurse skill mix have
been linked to improved outcomes, such as lower patient mortality and wound infections, and reduction in
medication errors.28 The focus of the review was on nursing care delivery based on one of two particular
models: team nursing and total patient care, and the effect these care models have on nurses’ wellbeing.
The reviewer acknowledged the importance of measuring patient clinical outcomes and organizational
factors to inform the delivery of safe and cost effective clinical care; however those outcomes where
excluded from the review as there have been previous reviews to inform practice in this area.29-31

The model of care is critical in defining the nursing work environment. Nursing work environments are
complex; prioritizing work is essential and the need to reprioritize nursing workloads on a daily basis is
often necessary. Research has shown that nursing work environments and also job satisfaction are
influenced by organizational structures, leadership, autonomy, models of care, multidisciplinary
collaboration and interpersonal relationships.20,32 Nursing organizational models vary in terms of scope
of practice, environment and staffing patterns and this can be as a result of nursing care restructuring.5

Ward areas may adapt different models of care due to the knowledge and skill level of staff, to influence
teamwork or to increase job satisfaction. Organizations need to manage within allocated resources and
ensure that they have the most appropriate model to support staff and ensure safe, effective clinical
outcomes. Regardless of the model of care, all nursing staff are required to work within their scope of
practice and have an understanding of their colleague’s roles and responsibilities. Confusion with scope
of practice leads to conflict, inter-professional rivalry and even bullying.33 Due to the global shortage of
nurses and skill mix issues, it is important to ensure the organizational model in the clinical area utilizes
the skills and experience of the available staff.
Page 18
1.3.5 Skill mix
Skill mix in this thesis refers to a classification of nurse employed for the provision of care. The overall
goal of a skill mix model is to allow for flexibility whilst achieving the most cost effective use of health
professionals, and the major influence on skill mix is financial implications.34 Due to nurses providing 24
hour care, their wages constitute a large proportion of hospital budgets. As a result, hospitals may
reduce nursing staffing as a way to reduce costs and increase profitability. 35 Other options include
re-engineering or redesigning the work which occurs through multiskilling the staff and developing their
knowledge to take on roles beyond their area of expertise, 34 and reducing registered nurse skill mix.
There are various skill mix combinations, including 100% registered nurses, and combinations of
registered nurses with either licensed nurses, nurses’ aides and/or unlicensed assistants. 34 When
determining the most sufficient number and mix of nursing staff, patient safety and care must be the
priority for decision makers.36 Studies have indicated that the lower the level of professional nurses the
higher the incidence of adverse patient outcomes.37 In McGillis et al. 2004 it was discovered that the
lower the nurse staffing skill mix the higher the number of nursing hours used.37 This in conjunction with
the negative effects on patient outcomes with a decreased staff skill mix, would indicate that it may not be
a cost effective strategy to reduce registered nurse skill mix. Tiedeman and Lookinland 2004, describe
that there are varying views regarding costs of nursing models. 19 Therefore, chapter 4 expands on the
discussion of cost effective care and the requirement for further studies to focus on an economic analysis
of skill mix, nursing models and their effects on patient and nurse outcomes.

1.3.6 Re-designing nursing work

These is an increase in patient complexity, acuity and chronic disease, as a result of this patients require
skilled nurses to care for them. A strategy organizational leaders may use to in an attempt to control costs
and manage workforce demands such as nursing staff shortages is to re-design the work that nurses
perform.38 This may include substituting experienced nurses for unskilled workers. 38 Duffield and
O’Brien-Pallas 2003 advise that “it may be counterproductive to employ unskilled workers as this may well
increase the workload and dissatisfaction of registered nurses, leading to an even greater shortage of
nurses long term.”38 (p.196) It has been argued that nursing models need to be reflective of current
workforce issues such as a reduction in registered nurse availability and increase in patient acuity.39 As
discussed there is a need to deliver cost effective health care without compromising patient safety and
care. There are advances in pharmaceuticals, constant changes in technology and an ageing population
which has seen health care expenditure continue to increase.40 In the discussion section of this thesis
restructuring, and realignment of services and the impacts on nursing work force is discussed further.

1.3.7 Scope of practice

The Australian Nursing and Midwifery Council 2007 describe scope of practice of a profession and of an
individual. A scope of practice of a profession is described as “roles, function, responsibilities, decision

Page 19
making capacity and functions that professions are educated and authorized to perform.”41(p. NP)

The scope of practice of an individual is described as “that in which the individual is educated , authorized
and competent to perform.”41(p.NP) Nurses Scope of practice may be specifically defined to a certain area of
practice they may need to undertake further knowledge and skills to be competent to practice within the
full scope of practice of the profession.41

Nurses’ roles and responsibilities continue to change due to financial constraints and workforce
shortages, as a result nurses’ need to be clear of the scope of practice of all those in their team to ensure
that roles and responsibilities are unambiguous.33

When allocating or assigning staff to care for patients, there is an assumption that the care is within the
individual’s normal responsibility and scope of practice. Delegation is different to allocating patients as
when delegating aspects of care there is a need to ensure that the person being delegated to, is
competent to perform the care. The person delegating the care retains accountability and needs to
monitor the outcome of the care delegated.42

1.3.8 Job satisfaction

Lu et al. 2005 discusses how job satisfaction is the most studied topic in organizational behavior. They
describe that the traditional model focuses on a person’s feeling about their job, however what makes a
job either satisfying or dissatisfying not only depends on the nature of the job but also the expectations of
what the job provides.43 Job satisfaction impacts on many layers of the nursing workforce including
absenteeism, stress, burnout and nursing turnover.

1.3.9 Stress and burnout

Workplace stress and burnout have implications for both the employee and the organization regardless of
the workplace. Jennings 2008 citing Lazarus who described stress as a “relationship between the
person and the environment that is appraised by the person as taxing or exceeding his or her resources
and endangering his or her wellbeing.”44(para1) If high stress levels are maintained this could result in
burnout. Burnout can be defined as physical or mental collapse caused by overwork or stress. 45 In
nurses, stress and burnout can have long standing implications for health and job satisfaction of the
nurse, and for the employer it can influence turnover and absenteeism.44 In addition, stress and burnout
have implications for patient care and with higher levels of burnout, nurses reported quality of care as
lower as described in Poghosyan et al 2010, which is a study of nurse burnout and quality care across six
countries.46

1.3.10 Absenteeism
Healthcare organizations depend on their workforce. Nurses are essential to care delivery and if they are
absent from work this can effect quality of care and have financial implications for the health care
organization.47 Davey et al. 2009 in their systematic review investigating absenteeism in hospitals

Page 20
discuss that burnout and job stress increases absenteeism, although there is no conclusive evidence
regarding nurse absenteeism specifically.48 Thus, with this uncertainty, problems and costs associated
with absenteeism will likely continue.48 Absenteeism may compromise patient care and increase
workload of other nurses’ as the unplanned leave may not be replaced or a less experienced nurse who is
unfamiliar with the area may be provided. This can also have a negative effect on the other nurses due to
increased workload resulting in increased absenteeism in the nursing team. 49

1.3.11 Turnover
Recruitment and retention of nurses is important and there is a need to understand the factors that
influence turnover however currently there is no universal definition to measure and determine nursing
turnover.50 This is further supported by Hayes et al. 2012 who describe that inconsistences in definitions
of nursing turnover and methodological differences limit the ability to measure and compare turnover, and
that studies focus on intent to leave when further studies are required on the cost to the system and
impacts of patient and staff outcomes.51 High turnover and the nursing shortage is of concern in many
countries as it impacts on the effectiveness and efficiency of health care delivery systems. 43

1.4 Introduction to systematic reviews

This thesis is based on a systematic review of the effectiveness of a team nursing model compared with a
total patient care model on staff wellbeing when organizing nursing work in acute care wards. A
systematic review was undertaken to ensure that there was a transparent, reproducible and systematic
approach to the identification and synthesis of the evidence. Systematic reviews include well-defined,
reproducible methodology covering the comprehensive search strategy, study selection, critical appraisal,
data extraction and data synthesis.52
Due to the nature of the research topic and methodological approach, the Joanna Briggs Institute (JBI)
systematic review process was used as JBI has a strong focus on healthcare. JBI has developed
systematic review tools to assist healthcare professionals to conduct systematic reviews of the best
available evidence, and the results can then inform clinical practice through evidence-based
recommendations for practice and further research.52

1.4.1 Characteristics of a systematic review

Systematic reviews are designed to answer specific research questions and as previously mentioned an a
priori protocol should be developed prior to undertaking such reviews. The protocol development
involves the construction of a specific research question, of which there is a need to check that there are
no current or impending systematic reviews on that specific topic. The title of the review should then be
registered to avoid duplication of the review. The protocol includes set parameters which include type of
participants and participant characteristics, the intervention, comparator and outcomes of interest. The
review protocol also includes how the methodological quality of studies will be assessed, how data will be
extracted and methods of synthesis for data extracted.52
Page 21
Following development of the question and the a priori protocol, a comprehensive search is undertaken to
identify all relevant published and unpublished evidence, and the retrieved citations are screened for
inclusion into the review. The studies selected must meet the review inclusion criteria set out in the
protocol.53 Methodological quality is assessed via critically appraisal of all papers by two independent
reviewers using a validated checklist, and data is then extracted from the included studies and
synthesised.54 Results are obtained and then conclusions and recommendations for research and
practice are made.52,53

1.4.2 Types of systematic reviews

There are various forms of reviews; Grant and Booth 2009 identified 14 review types and associated
methodologies mapped against the Search, Appraisal, Synthesis and Analysis (SALSA) framework.54
The Joanna Briggs Institute describes the following systematic reviews of evidence include; quantitative
evidence, qualitative evidence, economic and text and opinion based evidence. Comprehensive reviews
may include two or more of these forms of evidence, these are further described below. Due to the need
for reviews of different types of evidence, JBI has recently developed methodologies for umbrella reviews,
scoping reviews, reviews of prevalence and incidence, aetiology, and reviews of diagnostic test accuracy.

1.4.2.1 Quantitative evidence

The research topic presented in this thesis was addressed using quantitative evidence. In quantitative
evidence when studies are performed using the same measurements, the same result/s are expected to
be achieved repeatedly, as the strength in quantitative evidence is in the fact that it is reliable,52 when
using a valid methodological approach. The effectiveness of an intervention depends on how the
intervention achieves the desired result, in terms of clinical effectiveness and its relationship between the
intervention and the clinical outcome.52 Experimental and observational studies are the two main
research designs for collecting quantitative data and making measurements. Experimental studies are
when there are two or more variables and one of these variables is manipulated by the researcher and the
effect on the other(s) is studied. Observational studies infer there is a relationship between the variables.
Quantitative evidence in terms of history and paradigm is outlined further in the thesis.

1.4.2.2 Experimental study design

An experimental design is considered the ideal study design, however due to reasons such as ethics an
experimental design may not be practical.55 In terms of experimental designs randomized controlled
trials (RCTs) are the best evidence as many variables, (such as in ideal RCTs with randomizing
participant selection), are controlled and thus the intervention alone is responsible for the difference in
outcome.55 Quasi-experimental or non-randomized studies aim to discover a relationship between two
variables. Participants are not randomized and due to less control of the variables, there is an increased
risk of bias and interpretation of results careful consideration as other factors may influence the result
other than the intervention.52
Page 22
1.4.2.3 Observational study design
Observational study designs are used extensively in healthcare research, and are used when it is not
appropriate to use experimental designs due to ethical considerations.52 Correlational and descriptive
designs are common observational studies. Correlational studies summarise associations between
variables and include cohort and case-control studies.52 Cohort studies can be prospective or
retrospective. Case-control studies use retrospective study designs, ‘case’ referring to participants who
have a particular condition compared to those in the ‘control’ who don’t.55 Descriptive designs do not aim
to determine a relationship between variables but look at basic information, for example prevalence of
disease.52,55 In addition, JBI acknowledge that expert opinion may be the best available evidence when
no research evidence exists.52

1.4.2.4 Qualitative evidence

Qualitative enquiry enables analysis of human experience, and cultural and social phenomena.56 Action
research, phenomenology, ethnography, grounded theory, feminist research and discourse analysis are
qualitative research methodologies.52 Qualitative methods are valuable in health care as these methods
allow for a greater understanding and insight into individuals’ experiences. Data is collected for qualitative
evidence from a range of methods including interviews, reflective journals, focus groups, group work and
field observations.

1.4.2.5 Economic evidence

In healthcare the costs also need to be considered as well as the health effects.52 Health economic
evaluation is described by Annemans 2008 as a “comparative analysis of both the costs and the health
effects of two or more alternative health interventions.”57(p8) Evaluation of costs occurs through four
methods of cost analysis, three of these are full economic evaluation and these include cost-effectiveness
analysis (CEA), cost-utility analysis (CUA) and cost-benefit analysis (CBA). The CEA compares not only
the costs of interventions but also the outcomes or effects. A CUA measures the monetary cost by
outcome of study or quality adjusted life years (QALY). In a CBA the cost of the intervention and the
outcome are measured. A cost-minimization analysis (CMA) is a partial economic analysis and as the
benefits and the consequences are assumed the same therefore cheapest option is preferred.52

1.4.2.6 Text and opinion-based evidence

Text and opinion-based evidence refers to expert opinions, commentaries and views that are presented in
various sources such as journals, magazines and reports. Expert opinion may be the best available
evidence when there are no research studies.52 It is also important that it is declared that the evidence
is opinion-based, to ensure that those who are reviewing the evidence are able to make their own
conclusions regarding the validity of what is presented.52

Page 23
1.4.2.7 Comprehensive reviews
A comprehensive review is when two or more forms of evidence are included in the review, types of
evidence may include quantitative, qualitative, textual or a health economic evaluation. 52

1.5 Science of statistical synthesis

As this thesis is based on a quantitative review it is important to have an understanding of the history of
quantitative methods. According to O’Rourke 2007, it was not until the 20th century that this began to
occur in medicine with the combination of clinical trial results.58 One of the first examples is Karl
Pearson, a British statistician who compared infection and mortality in soldiers who were inoculated
against typhoid compared to those who were not, and this required regrouping of study observations.
Karl Pearson is considered the first person to analyze clinical trials using meta-analysis.58 At the time it
was not known as meta-analysis; this would not occur until Glass’s work. Gene Glass in 1976 published
his work titled, ‘primary, secondary, and meta-analysis of research,’59 where he first described the term
meta-analysis. Glass 1976 defines meta-analysis as combining study findings and a statistical approach
to combining these results.59 Below is a discussion around paradigms and explains which paradigm
statistical synthesis aligns to.

1.6 History of research methodology paradigms

A paradigm can be described as a way of viewing the world. 60 Explained further by Guba and Lincoln
1994, a paradigm is a “set of basic beliefs (or metaphysics) that deals with ultimates or first principles. It
represents a worldview that defines, for its holder, the nature of the "world," the individual's place in it, and
the range of possible relationships to that world and its parts.”61 (p.106). Four common paradigms for
research methodologies are positivist, interpretivist, radical and post-structural paradigms.62 Scotland
2012, explains that there are four components to a paradigm; the ontology, epistemology, methodology
and methods. He describes these individually as ontology constituting reality of what is, epistemology
involves how knowledge is acquired and communicated, methodology questions the why, what, where,
when and how data is analyzed and collected and finally methods is the specific techniques used to
collect and analyze the data.63

In the 19th Century Auguste Comte developed the term positivism; this paradigm emphasized the need for
systematic, objective, detailed observation and testing hypotheses through experimentation.62 Grant
and Giddings 2002, discuss how the interpretive paradigm looks at what it means to be human and the
meanings people attach to events. The interpretive paradigm sees the positivist view as a reductionist
approach to the human experience. They describe with the radical paradigm that there are two social
theories which relate to the paradigm, one being critical social theory the other the feminist theory,
although not all feminist theory belongs in this paradigm as feminist poststructuralism is a post-structural
paradigm. The radical paradigm is concerned with inequalities and injustices and the need to do

Page 24
something about this, examples of these inequalities includes gender, sexual preference, ethnicity and
class.62 Grant and Giddings 2002, discuss that the poststructuralist paradigm is also known as
deconstructivism or post postmodernism. They explain that they refer to this paradigm as
poststructuralist as they feel that the term postmodernism describes a historical era. This paradigm
‘rests on the assumptions that no-one can stand outside the traditions or discourse of time.’62 (p.20).

Positivism refers to a rational and empiricist philosophy that originated with such names as Aristotle, John
Locke and as mentioned previously Auguste Comte.60 Lockwood et al. 2011, describes that the positivist
paradigm is concerned with quantitative theory and aims at controlling the physical world and is different
from that of a subjective, qualitative or personal experience.55 With this paradigm and scientific method
of experimentation and adherence to utterly objective, accurate and valid scientific knowledge, positivism
is lacking in terms of applying human behaviours.60 In the late 1960’s the rigid view of positivism was
challenged by people such as the physicist and philosopher Thomas Kuhn with the postpositivist view that
researchers are influenced by cultural, political and social circumstances.62

1.7 Narrative synthesis

Narrative synthesis “is an approach used in systematic reviews to synthesise findings from studies and
relies on the use of words and text to summarise and explain the findings of the synthesis.”64(p.5) Narrative
synthesis should not be confused with narrative reviews which often lack a sound methodological
approach. These are considered the more traditional literature review and they are not transparent or
systematic in the synthesis process.65 At times it is not possible to combine data through meta-analysis
in quantitative reviews, therefore a narrative synthesis may be required.

1.8 Evidence-Based Practice (EBP)

As discussed this thesis is based on a quantitative review, therefore this section will focus on
evidence-based practice in terms of quantitative evidence. In health care the Greek physician
Hippocrates’ view of disease conditions is considered the earliest form of empiricist view, and this
continued with the very rationalistic views of Galen (Claudius Galenus).66 Parker 2005 also comments
that this empiricist view continued through the Dark and the Middle Ages due to Christianity belief in god
and the ancient authority of Hippocrates and Galen. This also influenced the medical profession which
became elitist and only those trained through the universities were accepted and other healing modalities
were excluded or devalued.66 This view then changed with the emergence of the Renaissance when
tradition was questioned which was due to threats to public health such as bubonic and syphilitic plague,
although in the 17th century there was still a reliance on the empirical view even with clear contradictory
evidence.66 In the late 20th Century the move to evidence-based practice really began. In the 1970’s
Archie Cochrane published the book ‘Effectiveness and Efficiency: Random Reflections on Health
Services’, within which he criticized the lack of reliable evidence behind accepted healthcare
interventions, highlighting the need for evidence-based medicine practices. He also discussed the need
Page 25
for a collection of systematic reviews of randomized controlled trials, and this led to the establishment of
the Cochrane Collaboration.67 The Cochrane Collaboration was established in 1993 under the guidance
of health researcher Iain Chalmers.

As the term evidence-based medicine (EBM) was first described by Dr. Gordon Guyatt in 1991.68 His
mentor was Dr. David Sackett and they had been using critical appraisal techniques at the bedside. He
originally termed this scientific medicine to describe the residency curriculum, however his colleagues did
not approve of this term, so he created the term evidence-based medicine.68 Evidence-based medicine
has been well described by Sackett et al. 1996, as “the conscientious, explicit and judicious use of best
current evidence in making decisions about the care of individual patients…integrating individual clinical
expertise with the best available external clinical evidence from systematic research.”69 (p.71) These
authors also discuss that systematic reviews do not need to be randomized controlled trials or contain
meta-analyses but identify the best external evidence to answer a clinical question.69

In the nursing profession, the concept of improving patient outcomes through evidence can be can be
traced back to Florence Nightingale’s 70 and her work on how the environment affected patient’s health.
The International Council of Nurses 2012, describe evidence based practice as “a problem solving
approach to clinical decision making that incorporates a search for the best and latest evidence, clinical
expertise and assessment, and patient preference values within a context of caring.” 71 (p.6) There has
been significant literature produced on the benefits of evidence based practice in nursing, and the need to
develop evidence based guidelines to inform practice.15

Grant and Giddings 2002, discuss that evidence-based practice is an example of a positivist approach to
knowing, and that research has focused on systematic reviews to highlight best practice, which becomes
the gold standard which is assumed will then lead to excellent care.62 They also discuss that randomized
control trials (RCT’s) produce the best evidence. Lockwood et al. 2011, discuss that systematic reviews
evolved from the positivist paradigm.55

It is important to note that there are a vast number of healthcare publications and clinicians need to be
able to interpret and assess the validity of these in order to make validated and credible changes to
practice and care.72 There are up to two million articles published a year across the healthcare
professions and with the internet health professionals and consumers need to ascertain what is good
quality information.53 Reviews feature widely in healthcare literature however they may not be
systematic reviews which have a peer-reviewed protocol, may not include an assessment of the quality of
included studies and synthesis may not be thorough, therefore there needs to be a clear process and rigor
around the systematic review process.53 The increasing amount of healthcare literature also applies to
systematic reviews with the establishment of various repositories for systematic reviews such as the

Page 26
Cochrane Collaboration, Joanna Briggs Institute, National Institute for Healthcare Excellence (NICE) and
Agency for Healthcare Research and Quality (AHRQ).73

1.9 Why undertake a systematic review

The purpose in undertaking the review was to compare the effectiveness of a team nursing model and a
total patient care model through evaluating which model of care achieves greater staff wellbeing. Staff
wellbeing was measured by staff outcomes in relation to staff satisfaction, turnover, absenteeism, stress
levels and burnout. The review focused on the acute care hospital sector and in particular general ward
settings. To avoid potential duplication of the proposed review topic, searches of the Joanna Briggs
Institute Database of Systematic Reviews and Implementation Reports and the Cochrane Library for
recent or underway reviews on similar topics were undertaken. The searches revealed that a systematic
review by Fernandez, et al.31 had recently been published on a similar topic and it looked at various
models of care and the effects those models had on staff such as staff satisfaction, role clarity and
absenteeism, and on patient outcomes in terms of nurse sensitive indicators, such as falls, medication
errors and infection rates. The review included some of the outcome measures reported in Fernandez,
et al.31 but extended the outcomes to include turnover, stress and burnout and narrowed the focus to two
models of care delivery. The purpose of replicating some of the outcome measures of staff satisfaction
and absenteeism was to extract a clear picture of the differences in the two care models, team nursing
and total patient care. There have been quantitative and qualitative reviews conducted on nursing
models and the effects on patient, organizational and staff related outcomes,29-31 but none had narrowed
the focus to these two models and their direct effect on staff wellbeing.

It was hoped that a quantitative systematic review would assist in informing practice regarding these two
care delivery models team nursing and total patient care by establishing the effect that each model has on
the nurses delivering them. The role of the RN includes delegation and this requires an understanding of
other team members’ scope of practice, education level and experience. In Australia, there are a number
of new hospitals being constructed or under redevelopment and the intent was for the review to assist in
informing practice on the preferred model of care. The review also looked at the impact of a team nursing
model and a total patient care model on staff wellbeing from a global perspective to ensure best available
studies which meet the criteria were included in the review. As mentioned the objectives, inclusion criteria
and methods of analysis for the review were specified in advance and documented in an a priori
protocol.1,2

The advantage of the systematic review was that it was conducted according to a priori protocol using the
Joanna Briggs Institute System for the Unified Management, Assessment and Review of Information
(JBI-SUMARI) software. Specifically, this systematic review utilised the Joanna Briggs Meta Analysis of
Statistics Assessment and Review Instrument (MAStARI), which is a reliable proven methodological tool
Page 27
which enables the critical appraisal and extraction of data from the included studies. As discussed in
Tricco et al 2008, the use of developing protocols for systematic reviews is important as protocols
minimise the risk of bias, as results are not known prior to developing the methods and hypothesis. The
authors also discuss that a cross sectional survey revealed that only 46.3% of published systematic
reviews report using a protocol.74

1.10 Statement of the review question

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

1.11 Defining the terms

It is important when undertaking a systematic review that the papers clearly define what is being
measured. This has been one of the limitations in undertaking a review into this topic because of the lack
of common terminology and definitions. The terms and measures used in this review are:

1. Nurse turnover which includes voluntary and involuntary termination, as well as internal and
external transfers.75 Voluntary termination may include transferring from one department to
another within the same organization or when nursing staff voluntarily leave or transfer from their
employment position. Voluntary termination excludes dismissals, voluntary retirement and
leaves of absence as a result of death, medical or maternity reasons or end of contractual
agreements.76 Involuntary termination is where employment is terminated by the employer.
Many studies do not distinguish between voluntary and involuntary turnover, therefore for the
purpose of this study nurse turnover will be defined as the process in which nurses leave or
transfer within the hospital environment.
2. Absenteeism (unplanned absence) in this review is defined as non-attendance at work where
work attendance is scheduled. This includes sick leave, and may include carer’s leave and
bereavement leave. This leave may be paid or unpaid. 77 Work related injury leave was
excluded.
3. Nurse stress is defined as the “relationship between the person and the environment that is
appraised by the person as taxing or exceeding his or her resources and endangering his or her
wellbeing.”44(para1)
4. Nurse burnout is the physical or mental collapse caused by overwork or stress.45
5. Skill mix is the combination or grouping of different categories of workers that are employed for
provision of care to patients.34 Categories of workers for this review specifically refers to nursing
staff employed for provision of care.

Page 28
Chapter 2 Methods

This chapter presents the systematic review method which the thesis has been developed from and
includes the review objectives, types of studies, the inclusion criteria and search strategy. One of the
requirements of a Joanna Briggs Institute (JBI) systematic review, is the publication of an a priori protocol
which will be discussed.

2.1 Review question and objectives

The objective of the systematic review which informed this thesis was to critically appraise and synthesize
the best available evidence on the effectiveness of a team nursing model compared with a total patient
care model on staff wellbeing when organizing nursing work in acute care wards. The review sought to
answer the following question:

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

2.2 Inclusion criteria

2.2.1 Types of studies
Quantitative studies that focused on but were not limited to staff turnover, absenteeism, staff satisfaction,
stress and burnout were considered for inclusion in the review. Experimental and epidemiological study
designs, including randomized controlled trials, non-randomized controlled trials, quasi-experimental,
before and after studies, prospective and retrospective cohort studies, case control studies and analytical
cross sectional studies, were considered for inclusion.

The review also considered descriptive epidemiological study designs, including case series, individual
case reports and descriptive cross sectional studies, for inclusion.

2.2.2 Types of participants

The review considered studies that included all nurses working on general wards in the acute care
hospital sector. This included registered general nurses or the international equivalent, such as staff
nurse and professional nurse; enrolled nurses or the international equivalent, such as licensed vocational
nurse or licensed practical nurse; and unlicensed personnel, such as nursing assistants or the
international equivalent, such as nurse’s aide and auxiliary nurses.
Excluded from the review were: Nursing staff working on specialized wards and areas, for example,
intensive/critical care areas, oncology wards, pediatrics, midwifery, mental health, primary care and aged
care sectors, as they use specific models of care for their scope of practice.

Page 29
2.2.3 Type of intervention and comparator
The review considered studies that investigated the use of a team nursing model when organizing nursing
work. The comparator was the use of a total patient care model.

2.2.4 Types of outcomes

The primary outcome of interest to the review was staff wellbeing. Data collection tools included
questionnaires for the collection of responses for staff satisfaction. As staff satisfaction and job
satisfaction are used interchangeably in the literature, outcomes which referred to job satisfaction were
included. Validated and reliable measurement tools were utilized in the selected articles to measure staff
burnout and stress levels. Nursing turnover and absenteeism rates were also extracted from the
included papers. Patient clinical outcomes were not considered the review, as the focus was on nurse
outcomes.

2.3 Search Strategy

The search strategy aimed to find both published and unpublished studies. A three-step search strategy
was conducted for the review. An initial limited search of PubMed and CINAHL was undertaken followed
by an analysis of the text words contained in the title and abstract, and of the index terms used to describe
the article. A second search using all identified keywords and index terms was then undertaken across
all included databases. See (Appendix II) for the complete search strategy. Initially, MedNar database
was included in the search strategy; however following consultation with the research librarian, MedNar
was omitted due to an inability to achieve specificity in the search results.

The databases searched were:

• CINAHL
• PubMed
• Cochrane Library (CENTRAL)
• Scopus
• Embase
• Science Direct.
The search for unpublished studies included:
• ProQuest Dissertations and Theses.

Thirdly, the reference lists of all identified reports and articles were searched for additional studies.
Studies published in the English language from January 1, 1995 to April 21, 2014 were considered for
inclusion in the review. In order to analyze the most current and contemporary body of evidence, the
review only considered published articles from 1995 onwards. To justify this time period it is critical to
reflect upon the changes that have occurred within the nursing profession in relation to a number of

Page 30
influences including nurse education, changes in health acuity, workforce demands and the introduction
of new nursing roles into the acute care health workforce. These influences have greatly affected and
influenced models of care delivery. Studies prior to this period of time, considering the significant
movements and changes in workforce dynamics would be superfluous to the outcomes of the systematic
review.

2.4 Assessment of methodological quality

Quantitative papers selected for retrieval were assessed by two independent reviewers for
methodological validity prior to inclusion in the review using standardized critical appraisal instruments
from the Joanna Briggs Institute Meta-Analysis of Statistics Assessment and Review Instrument
(JBI-MAStARI). Due to the limited availability of studies in the literature, it was decided not to exclude
papers based purely on quality. The studies were grouped into randomized controlled
trials/pseudo-randomized trials, comparable cohort/case control studies or descriptive/case series studies
to enable the reviewers to assess methodological quality (see Appendix III). A third reviewer was not
required as there was consensus amongst the two reviewers.

2.4.1 Data collection

Data were extracted from papers included in the review using the standardized data extraction tool from
JBI-MAStARI (Appendix IV). The data extracted included specific details about the interventions,
populations, study methods and outcomes of significance to the review question and specific objectives;
see (Appendix V) for tabulated characteristics of included studies

2.4.2 Data synthesis

There was significant methodological, clinical and statistical heterogeneity in the included studies, with
differences in study designs, outcome measures and statistical analyses. Due to this heterogeneity,
meta-analysis was not possible and results from the review have been presented in a narrative form, in
the result section.

Page 31
Chapter 3 Results

This chapter outlines the results of the systematic review, as published in the JBI Database of Systematic
reviews and Implementation Reports.3 This chapter includes the identified studies, their methodological
quality, results as to the effectiveness of a team nursing model compared with a total patient care model
on nurses’ wellbeing and a synthesis of the findings.

3.1 Search and study selection

A comprehensive search of electronic databases was performed. The database search returned 10,067
records (Figure 1). A total of 3268 duplicate records were removed resulting in 6799 papers that were
screened on the basis of title and abstract, and of these 6756 were considered ineligible for inclusion in
the review.

Forty-three full text titles were retrieved and assessed for eligibility for inclusion in the review. Forty
articles were excluded and rationale for their exclusion documented (Appendix VI). This resulted in three
articles being included in the review. Reference lists of included studies (Appendix VII) were screened
for further potentially relevant articles; however no further studies were identified that met the inclusion
criteria.

Page 32
 Records identified through database Records identified through other
searching sources
Identification

(n =10,067) (n =0)

Duplicates removed
(n = 3268)
Screening

Records screened by title Records excluded

and abstract (n = 6756)
(n = 6799)

Full-text articles assessed for Full-text articles excluded,

Eligibility

eligibility with reasons

(n = 43) (n = 40)

Studies included in narrative

Included

summary
(n =3)

From: Moher D, Liberati A, Tetzlaff J, Altman DG, The PRISMA Group (2009). Preferred Reporting Items for Systematic
Reviews and Meta-Analyses: The PRISMA Statement. PLoS Med 6(6): e1000097. doi:10.1371/journal.pmed1000097
Figure 1 - Study identification process

Page 33
3.2 Methodological quality
Three studies were selected for inclusion in the review and their methodological quality assessed using
the JBI critical appraisal tool for randomized/pseudo-randomized controlled trials (Table 1). Although
Wells et al.78 was described as a mixed method, longitudinal, descriptive study, it was considered to be an
uncontrolled before and after experimental study. None of the included studies18,20,78 used
randomization to allocate participants to treatment groups, nor blinded participants to treatment allocation;
however due to the nature of the studies it would not have been feasible to assign treatment groups
randomly or blind participants to the intervention. None of the studies indicated that the allocation of
treatment groups was concealed from the allocator, placing these studies at risk of selection bias. Small
sample size was of concern in all of the studies. Risk of attrition bias was present in two of the
studies20,78 as drop out of participants was high over the course of the study, in particular in Tran et al. 20
and Wells et al.,78 and outcomes of people who withdrew was not fully described. Several reasons for
the low response rates are explained in both Wells et al.78 and Tran et al.,20 such as length of survey, staff
shortage and resistance to change. None of the included studies blinded the assessors of outcomes to
the treatment allocation of the groups, placing all studies at risk of detection bias.

Two studies18,20 had comparable control and treatment groups; however this was not applicable as there
was no control group in Wells et al.78 The strength in all of the studies was that all groups were treated
identically besides the named intervention, and outcomes were measured the same way for each group in
the individual studies, although Fairbrother et al.18 did perform a further analysis on nurses’ job
satisfaction in the intervention wards only. The three studies used reliable tools to measure outcomes,
with one study18 adapting a pre-existing tool to meet the local context needs. Appropriate statistical
analysis occurred in each, although it may have been appropriate to perform a statistical power analysis to
account for differences in sample sizes due to large reduction of survey responses at follow up in Wells et
al.78 and Tran et al.20

Table 1 - Methodological quality of included studies

Citation Q1 Q2 Q3 Q4 Q5 Q6 Q7 Q8 Q9 Q10

Fairbrother G, Jones A, N N N N N Y Y Y Y Y
Rivas K. (2010)18

Tran DT, Johnson M, N N N U N Y Y Y Y Y

Fernandez R, Jones S.
(2010)20

Wells J, Manuel M, Cunning N N N N N NA Y Y Y Y

G. (2011)78

Page 34
3.3 Description of included studies
Three studies were included in the review; two studies were conducted in Australia18,20 and one was
conducted in Canada.78 See (Appendix V) for the characteristics of the included studies. This
systematic review focused on two models of care, team nursing and total patient care; however the
terminology used to describe the models of care varied in the studies. For example, the term shared care
in nursing (SCN) was used in Tran et al. 20 to describe a model of care that was considered equivalent to
a team nursing model as defined by this review. Table 2 outlines the models of care as described in
included studies and alignment with terminology in this review.

Table 2 - Models of care as described in included studies and in alignment with terminology in review

Study Model of care as described in included studies Alignment with review

terminology
Fairbrother et al. (2010)18 Team nursing model of care: In this model there is a shared Team nursing
responsibility approach to team nursing and not a task
allocation style. Some of the wards had team leaders, some
had shift coordinators and others created leaderless teams.

Individual patient allocation (IPA) model of care: In this model

one nurse assumes the responsibility for the complete care of Total patient care
a group of patients on a one–on-one basis during that shift.
Tran et al.(2010)20 Shared care in nursing (SCN) model: This model involves Team nursing
RNs ENs and AINs working in teams to deliver care.

Patient allocation (PA) model. This model involves one RN

responsible for total care of a number of patients. It does not Total patient care
guarantee continuity of care throughout the patient admission.
Wells et al.(2011)78 Modified total patient care (TPC) involves the assigning of Total patient care
care to an individual nurse during the shift.

Team nursing: This is not described. Team nursing

Findings of the review: Description of individual studies

Fairbrother et al. (2010) 18

The Fairbrother et al.18 study compared job satisfaction, nurses’ experiences and staff turnover when
changing the model of care from total patient care to team nursing. Twelve medical and surgical
wards/units participated with six wards/units changing from a total patient care model to a team nursing
model, and six remaining with the total patient care model. The participants included registered nurses,
enrolled nurses, new graduate registered nurses and clinical nurse specialists. A hospital-wide survey
was distributed at baseline with a total of 221 nursing staff being surveyed; this included 42 responses
from staff not included in the study as the whole hospital had been surveyed, including areas such as
intensive care. The survey was repeated 12 months after implementation of the team nursing model.
The outcomes of interest for this review were job satisfaction and staff turnover.

Page 35
Tran et al. (2010)20

The Tran et al.20 study compared job satisfaction and stress of nurses working within team nursing and
total patient care models. There were four intervention wards which introduced a team nursing model
compared to four wards which maintained a total patient care model. The participants included
registered nurses, enrolled nurses and assistants in nursing. At the commencement of the study there
were 150 nurses eligible for inclusion in the study and questionnaires were distributed to these staff
members, with 125 returned. There were 51 responses from the total patient care model wards and 74
from the team nursing model wards. The demographics for both groups were similar at commencement
of the study, predominantly registered nurses or clinical nurse specialists. The same survey was then
redistributed six months post-introduction of the team nursing model with 53 total responses; 39 from
team nursing model wards and 14 for the total patient care model wards. It is important to note that Tran
et al.20 described their patient allocation model as one registered nurse being responsible for the total care
of a number of patients without guarantee of continuity of care throughout the patient admission; therefore
in terms of this review it aligned with a total patient care model. However if the nurse was responsible for
the patients’ entire hospital stay then it would have been considered a primary care model. Outcomes of
interest for this review were job satisfaction and stress.

Wells et al. (2011)78

Wells et al.78 study was conducted on two acute care nursing units which previously practiced a team
nursing model and changed to a total patient care model to assess how the change affected nurses’ job
satisfaction, empowerment and care effectiveness perceptions. The study was conducted over a
12-month period with three phases of data collection, at pre-implementation and then at three months and
12 months. The potential sample size was 118 which included 70 registered nurses, eight licensed
practical nurses, and 40 casual and relief staff. Self-report surveys were distributed to these nurses. The
response rate for registered nurses was 31 at pre-implementation, 28 at three months and 18 at 12
months. The licensed practical nurses’ response rate at pre-implementation was eight, the three months
response rate was seven, and the 12 months response rate was three. The casual and relief staff
response rate was five at pre-implementation and three at three months. There were no licensed
practical nurse responses from the casual and relief staff at 12 months. Data from registered nurses and
licensed practical nurses was combined due to the low response rates. The outcome of interest for this
study was job satisfaction.

Page 36
3.4 Results: Outcome measures

3.4.1 Job satisfaction

Job satisfaction was reported in the three included studies,18,20,78 (Table 3) with each study using a
different method to ascertain job satisfaction. All studies used a questionnaire or survey to obtain data.
Fairbrother et al.18 measured job satisfaction using the Nursing Workplace Satisfaction Questionnaire
(NWSQ) tool79 which was developed by the authors in 2009 for this study as existing tools to measure
satisfaction were seen as too long, and considered to be US biased.79 The NWSQ tool identified three
domains to measure job satisfaction: intrinsic, extrinsic and co-worker. Intrinsic was classified as job
satisfaction within each individual nurse, extrinsic was classified as satisfaction with the work
environment, and co-worker was considered as job satisfaction with fellow nurses. The scoring scale
indicates that a lower score corresponds to a higher satisfaction level. Tran et al.20 measured job
satisfaction using the Job Descriptive Index (JDI), which includes satisfaction with work, supervision and
co-workers, and the global Job in General (JIG) scale.80,81 Each scale consists of 18 items and nurses
were required to describe each component of the JDI and global JIG. In this tool, higher scores indicate
higher levels of job satisfaction. Wells et al.78 measured job satisfaction using the Index of Work
Satisfaction (IWS).82 This is a two part tool: part A assesses perceived importance and calculates using
a weighting coefficient, and part B is a seven-point Likert scale and provides an overall mean of six job
variables which include interaction, status, autonomy, tasks, policy and pay, with higher scores indicative
of higher satisfaction. As a result of different tools used to measure job satisfaction, meta-analysis of
results was not appropriate.

Table 3 - Job satisfaction

Study Data
and measure
Fairbrother et al. Mean job satisfaction scores at 12 months for team nursing and total patient care wards
(2010)18
Team nursing wards (n=6) Total patient care wards (n=6) ANOVA F (P) differences between team
Mean (95% CI) Mean (95% CI) nursing and total patient care wards
Self-
completion
surveys Intrinsic 12.4 (11.4-13.4) 13.5 (12.5-14.5) 1.7 (0.18)
NWSQ Tool
Extrinsic 11.3 (10.7-11.9) 12.7 (12.0-13.4) 5.4* (0.005)

Co-worker 7.2 (6.7-7.7) 7.5 (7.0-8.0) 0.32 (0.73)

Total 30.9 (29.1-32.7) 33.5 (31.7-35.3) 2.6 (0.077)

Page 37
Study Data
and measure
Fairbrother et al. Mean job satisfaction scores by nursing staff classification on team nursing wards at baseline and 12 months
(2010)18
Baseline staff 12 month Intrinsic
Self- Intrinsic Extrinsic Extrinsic Total Total 12
completion number staff number 12
Baseline baseline 12 months baseline months
surveys response response months
NWSQ Tool
Enrolled Nurses 15 16 9.9 10.4 9.8 10.3 26.2 27.6

Graduate Nurses 7 7 14.6 10.3** 12.6 9.8** 34.6 28.3

Registered
54 51 14.2 13.2 13.0 11.8* 34.9 32.0**
Nurses

Clinical Nurse
17 17 12.2 12.2 12.7 11.7 32.4 31.3
Specialist

*(p less than 0.05) –Statistically significant

** (p 0.05 and 0.20) –Notable difference

Study Data
and measure
Tran et al.
(2010)20 Mean job satisfaction scores on team nursing and total patient care wards at baseline and 6 months

Within Group Between Group

Self - Mean (SD)
administered Mean difference
survey at (follow-up-baseline)
baseline and then Team nursing Team nursing Total patient Total patient care Team Total
repeated at
–baseline follow-up 6 care –baseline follow-up 6 nursing patient care
follow-up (6
months) (n=74) months (n=39) (n=51) months (n=14) (n=25) (n=13)
Work 41.28 42.33 39.73 41.29 0.34 3.38
Job descriptive
Index and Job in (ROS 0-54) (7.85) (9.56) (10.65) (14.11) (12.56) (10.23)
General scale
Tool Supervision 42.58 41.55 39.4 36.23 -2.88 0.50
(ROS 0-54) (10.13) (13) (10.99) (13.54) (16.26) (2.15)

Co-worker 41.78 37.44* 41.15 40.57 -0.75 1.92

(ROS 0-54) (10.17) (11.8) (10.89) (13.21) (15.67) (9.88)

Global 41.29 40.6 41.87 43.64 -1.60 0.67

(ROS 0-54) (8.84) (10.61) (11.65) (7.97) (15.33) (7.84)
*(p less than 0.05) –Statistically significant
(ROS):Range of scores for job satisfaction

Study
and measure Data

Wells et al. Ranking of most important job variables

Pre-
(2011)78 12 months
implement 3 months weighting
Variable Variable Variable weighting
weighting coefficient
coefficient
Self- coefficient
completed Pay 3.44 Pay 3.64 Pay 3.73
surveys Tasks 3.32 Autonomy 3.35 Autonomy 3.16
Index of work Autonomy 3.22 Interaction 3.30 Interaction 2.94
satisfaction Tool
Status 3.10 Tasks 3.19 Status 2.84
Interaction 3.03 Status 3.17 Tasks 2.77
Policy 2.29 Policy 1.96 Policy 2.31

Page 38
 Ranking of satisfaction with variables

3 month 12 month
Variable Pre-mean Variable Variable mean
mean
Status 5.00 Status 5.06 Status 5.08
Interaction 4.53 Interaction 4.44 Interaction 4.43
Autonomy 4.18 Autonomy 4.05 Autonomy 4.29
Tasks 2.81 Pay * 2.79 Tasks 2.58
Policy 2.38 Tasks 2.72 Policy 2.24
Pay 2.23 Policy 2.18 Pay 2.23

Overall Index of work 3.64 Overall Index of work 3.66 Overall Index of work 3.64
satisfaction satisfaction satisfaction

*(p less than 0.05) – Statistically significant

There was no statistically significant difference observed in any study in the overall job satisfaction of
nurses using a team nursing model compared with a total patient care model.18,20,78 Some differences in
job satisfaction were however observed within different subgroups of nurses and within various domains
of job satisfaction utilized by the studies. In assessing job satisfaction in all nurses according to domains
of intrinsic, extrinsic and coworker, Fairbrother et al.18 showed that there was a lower score for extrinsic
job satisfaction which demonstrated a statistically significantly higher extrinsic job satisfaction in the team
nursing model wards (mean 11.3; 95% CI 10.7-11.9) compared with total patient care model wards (mean
12.7; 95% CI 12.0-13.4) at 12 months; this was a significant difference of 5.4 (p = 0.005) between the two
groups using the Analysis of Variance ANOVA F (P) test. There were no statistically significant changes
in intrinsic job satisfaction on team nursing model wards (mean 12.4; 95% CI 11.4-13.4) and total patient
care model wards (mean 13.5; 95% CI 12.5-14.5). There was no statistically significant difference with
satisfaction with co-workers on the team nursing model wards (mean 7.2; 95% CI 6.7-7.7) compared to
total patient care model wards (mean 7.5; 95% CI 7.0-8.0).

In assessing results according to nurse classification, Fairbrother et al.18 identified the team nursing model
as favorable for new graduates compared to the previous model of total patient care, as job satisfaction in
all domains improved for graduate nurses working on wards using the team nursing model; however these
results were not statistically significant. There were notable increases in intrinsic job satisfaction
(baseline mean score 14.6, 12 months mean score 10.3; p between 0.05 and 0.20) and extrinsic job
satisfaction (baseline mean score 12.6, 12 month score 9.8; p between 0.05 and 0.20); however with
limited participants in this classification group (n=7), a statistically significant difference was not expected.
There was a statistically significant difference in the registered nurses’ extrinsic job satisfaction (baseline
mean score 13.0, 12 months mean score 11.8; p less than 0.05). Total satisfaction for this group had
also improved with a notable difference (baseline mean score 34.9, 12 months mean score 32; p between
0.05 and 0.20). Enrolled nurses had an overall higher job satisfaction than any other classification at
baseline and follow-up at 12 months; however total job satisfaction did decrease with the introduction of a
Page 39
team nursing model (baseline mean score 26.2, 12 months mean score 27.6). Total job satisfaction
scores increased for nurses of all other classifications.

Tran et al.20 demonstrated that nurses experienced high levels of job satisfaction regardless of the model
of care, with scores of 75% or more of maximum scores of job satisfaction achieved using both models.
There was a decrease in staff satisfaction with co-workers following introduction of a team nursing model,
with a statistically significant (p less than 0.05) decrease between baseline (mean 41.78; SD 10.17) and
follow-up at six months (mean 37.44; SD 11.8). The authors noted that job satisfaction was influenced by
tension, increasing levels of stress and uncertainty in role.

There were no significant changes in nurses’ job satisfaction following a change from a team nursing
model to a total patient care model in Wells et al.,78 however the authors suggest variables other than the
model of care were shown to influence job satisfaction. Nurses consistently ranked pay as the most
important job variable and policy as the least in the index of work satisfaction tool. The only significant
difference with job satisfaction ranking with the variables was nurses’ job satisfaction with their pay at
three months, with a mean of 2.79 (p=<0.05), as compared with a mean of 2.23 at pre-implementation and
2.23 at 12 months. The positive change at three months was likely due to nurses receiving retroactive
pay at this time. At 12 months, pay was once again the variable with which nurses were least satisfied.
Nurses perceived interaction as having greater importance following the introduction of a total patient care
model as this had ranked as fifth most important job variable at baseline, but this then went to third out of
the six criteria at the three and 12 months review. This may have been a result of a decrease in
interaction with other nurses due to the move from a team nursing model to a total patient care model, and
nurses recognized that there was a loss of interacting with other nurses in the total patient care model
which then increased their ranking of this variable.

3.4.2 Stress
Stress was reported in one of the included studies (Tran et al.)20 (Table 4), which measured stress using
the Stress in General (SIG) Scale.83 The SIG scale has 15 items with two subscales, pressure at work
and work-related threat. Job tension was also included and was measured using the Tension Index
developed by Lyons.84 In this tool the higher the score the higher the level of tension as measured by the
frequency of feeling bothered by various work factors. As shown in Table 4 there were no statistically
significant differences in either stress or job tension between wards using the team nursing model or the
total patient care model.
Table 4 – Stress
Study and Data
measure
Tran et al. Mean stress and job tension scores on team nursing and total patient care wards at baseline and six months
(2010)20

Page 40
 Between Group
Within Group
Self - Mean difference
Mean (SD)
administered (follow-up-baseline)
survey at Total patient Total
baseline and then Team nursing Total patient
Team nursing care follow- Team nursing Patient
repeated at follow-up 6 care baseline
baseline (n=74) up 6 months (n=25) care
follow-up (6 months (n=39) (n=51)
(n=14) (n=13)
months)
Pressure
Job descriptive (ROS 12.38 12.55 11.98 11.62 0.08 -0.58
Index and Job in 0-14) (3.96) (3.43) (4.18) (4.46) (4.13) (3.09)
General scale
Tool Threat
(ROS 8.51 8.78 7.87 8.00 1.00 -0.92
0-16) (5.61) (4.77) (5.84) (5.94) (6.27) (4.89)
Tension
(ROS 23.27 23.11 23.06 25.74 -0.46 -0.97
9-45) (6.1) (5.5) (6.1) (6.9) (7.67) (2.94)
Range of scores (ROS) for pressure, threat and tension

3.4.3 Burnout
No identified studies addressed burnout when comparing a team nursing model with a total patient care
model.

3.4.4 Absenteeism
No identified studies addressed absenteeism when comparing team nursing model with a total patient
care model.

3.4.5 Staff turnover

Staff turnover was reported in one of the included studies, Fairbrother et al.18 measured staff turnover by
dividing the vacancy rate with the number of full time equivalent (FTE) nursing staff. Table 5 presents the
combined ward vacancy rates at baseline and 12 months follow-up for the team nursing model wards and
total patient care model wards and includes the improvement in vacancy rates by percentage.

There was a decrease in vacancy rates in both the team nursing model and total patient care model
groups from baseline to follow-up at 12 months. The vacancy rate improved by 75% in team nursing
model wards and by 41% in total patient care model wards, suggesting that while there was a reduction in
vacancy rates in both groups, staff turnover may be reduced with a team nursing model compared with a
total patient care model; however these results were not statistically significant. The data was subjected
to a Mann-Whitney test U =10; P=0.20 and it did not show a statistically significant result. Therefore it
cannot be determined whether a team nursing model or a total patient care model directly affected
turnover; however the team nursing model wards improved vacancy rates faster than the total patient care
model wards.

Page 41
Table 5 - Staff turnover
Study and Data
measure
Fairbrother et al. Total Full Time Equivalent (FTE) vacancies on team nursing and total patient care wards at baseline and 12 months.
(2010)18
Follow-up Follow-up Per cent (%)
Number of FTE Baseline Baseline
(12 months) (12 months) Improvement
vacancies FTEs vacancy rate
FTEs vacancy rate (vacancy rate)
divided by FTE’s
allocated Team nursing total 54.1 12.7 0.32 0.08 75

Total patient care

total 31.8 15.7 0.23 0.13 41

Non-parametric statistical testing(Mann-Whitney U =10.0; P=0.20)

Page 42
Chapter 4 Discussion and Conclusions

This chapter constitutes the discussion, conclusions, implications for practice and further research in the
area of nursing models and their effect on staff wellbeing when organizing nursing work in acute care
wards.

4.1 Discussion

4.1.1 Nursing Models and Staff Wellbeing

This thesis is based on the systematic review that sought to establish, through the best available
evidence, the effectiveness of a team nursing model compared with a total patient care model on staff
wellbeing when organizing nursing work in acute care wards. Staff wellbeing was measured by staff
outcomes in relation to staff satisfaction, turnover, absenteeism, stress levels and burnout. Due to the
limited number of quantitative studies that could be included, the review could not conclude whether a
team nursing model or a total patient care model is the preferred model when addressing these outcomes.
Several studies32,85-91 investigating models of care were excluded from the review for a variety of reasons,
including using hybrid models of care, ambiguity around the model of care used, using multiple models of
care, or reporting on patient rather than nurse wellbeing outcomes. The findings of these studies,
however, can contribute to the discussion regarding which is the best model of care and will be discussed
below. The review demonstrated that there needs to be consistency in terminology to describe the
various models of care. There is also a requirement for agreed methodologies and tools to measure
aspects of staff wellbeing to enable reliable data extraction and synthesis.

The review did not consider qualitative data, however all of the included studies18,20,78 had a qualitative
component and reported themes regarding aspects of either team nursing or total patient care models that
nurses experienced as either positive or negative. In the Fairbrother et al.18 study, the positive aspects of
changing to a team nursing model from a total patient care model identified by nurses included greater
support for inexperienced staff, role clarity, greater communication and teamwork. The negative themes
included senior nurses preferring the total patient care model as they felt this was more personally
satisfying, and senior enrolled nurses feeling a loss of autonomy within the team nursing model.18 In
Tran et al.20, team leaders perceived the benefits of a team nursing model as increased confidence in
communicating with nursing staff and medical staff, increased time management and prioritizing skills,
improved relationships with team members, patients and medical staff, the opportunity to support new
team members and the ability to focus on patients’ needs. The detrimental aspects of the team leader
role as perceived by some of the registered nurses surveyed included increased workload, responsibility
and stress.20 Wells et al.78 reported positive responses from nurses who were using the total patient care
Page 43
model including enhanced professional practice, clear accountability and increased coordination of care.
The challenging aspects identified included communication issues, lack of ongoing support, care plan
issues and missed care. Other research92 has described benefits of a team nursing model perceived by
nurses as allowing for a patient-orientated approach as all the nurses were familiar with the patient care
needs, increased supervision and enhanced quality of patient care. Collectively, these results suggest
that staff were more concerned with specific aspects of models of care, such as role clarity,
communication, teamwork, supervision, patient care needs and support for staff, rather than the model of
care per se. Other factors such as leadership, teamwork, role ambiguity, scope of practice, experience
and skill mix were therefore likely to influence staff wellbeing rather than solely the nursing model.

The included studies18,20,78 demonstrate that whilst there were some significant differences between a
team nursing model and a total patient care model in certain subgroups of nurses or within various
domains of job satisfaction, the model of care did not have a significant effect on the total job satisfaction
of nurses. This is supported by Adams and Bond32,86 who concluded that staff resources, stability in the
workforce and ethos of care had greater influence on nurses’ job satisfaction than the organizational
system in place. This was also the case in Kangas et al.93 who compared team nursing, primary and
case management nursing models. This study concluded that there was no difference in nurses’ job
satisfaction between the nursing care delivery models and that a supportive environment was the main
component of nurse satisfaction.

The systematic review also demonstrated that job satisfaction is influenced by multiple factors related to
nursing and not necessarily the model of care in place, although factors such as nursing experience, ward
size, ward stability and skill level can impact on job satisfaction and should be considered when
establishing which model of care to implement. Where staff are new and inexperienced, a team nursing
model may be the appropriate model. Fairbrother et al.18 identified that novice nurses, in particular new
graduate nurses, had greater job satisfaction with a team nursing model. Tran et al.20 also suggested a
team nursing model may be appropriate if there is a mix of nursing staff with varying experience and skill.
The team nursing model is documented in the literature as a model which supports novice nurses when
there is a lower registered nurse skill mix.31 In one study, Sjetne et al.88 looked at primary nursing, team
nursing and a hybrid model of the two to assess the relationship of these models with job satisfaction.
Job satisfaction was influenced by the size of the ward and was lower in larger wards. Job satisfaction in
all wards was positive if shifts were staffed to rotation plan. Agency utilization also contributed to a
negative association of job satisfaction, which was also the case in another study.86 These studies
indicate that where there is a higher experienced registered nurse skill mix, then a total patient care model
may be appropriate, but where there is a higher skill mix of inexperienced registered nurses, enrolled
nurses or assistants in nursing, then a team nursing model should be considered to support and guide
these nurses.

Page 44
Nurses’ job satisfaction will differ for each nurse regardless of the nursing model of care in place but as the
review identified there are similarities in factors that contribute to job satisfaction, including leadership,
supervision, quality of care, working conditions, relationships with co-workers and pay. The need for
effective leadership and support when changing the model of care was also a recommendation in Wells et
al.78 A literature review by Lu et al.43 on job satisfaction among nurses identified that although job
satisfaction levels differed for individual nurses there are common sources of job satisfaction, such as
“physical working conditions, relationships with fellow workers and managers, pay, promotion, job
security, responsibility, the recognition from managers and hours of work.”43(p215) Nurses view leadership
and supervision as important factors in their levels of job satisfaction, this was highlighted in McGillis Hall
and Doran,87 who concluded that there were positive associations between job satisfaction and views of
leadership. The need for effective leadership, supervision and accountability is crucial to ensure effective
ward environments,23,78,94,95 and these factors may influence nurses job satisfaction more so than the
model of care in place.

The other outcomes of interest in the review may also be influenced by factors other than the nursing
model of care. As discussed in McGillis Hall and Doran87, factors such as quality of care, nurses’
perceptions of leadership and patient complexity can influence nurses’ stress levels. This study
demonstrated that a total patient care model had a statistically significant negative influence on nurses’
job pressure and therefore concluded that models which do not use a total patient care model may
contribute to nurses’ job pressure. It is also important to note that this study was conducted on wards
where the majority (83.1%) used a total patient care model. When looking at absenteeism, Kivimaki et
al.89 compared primary nursing with team nursing over three years, and showed that the model of care
did influence sickness absence and that a primary nursing model was associated with higher sickness
absence than a team nursing model. Nursing organizational models were not identified as a predictor of
absenteeism in a systematic review by Davey et al.48 which investigated predictors of nurse absenteeism
and revealed that predictors of absenteeism included nurse’s absenteeism history, nurses’ job
satisfaction, job involvement, organizational commitment, staff retention, stress and burnout.

The review was unable to determine if a team nursing model or a total patient care model affected staff
turnover, as turnover was seen to improve under both models in the one study that reported this
outcome.18 A recent literature review51 discusses numerous influences which affect turnover such as
workload, work environment, organizational structure, stress, burnout, management style, empowerment,
role perceptions, career advancement, pay and individual factors. They also highlight that job
satisfaction is a greater predictor of intent to leave than age, working shifts and promotion. Overall,
nurses who are satisfied in their job are more likely to remain in their current roles. 96

As already identified in the results section there was no statistically significant difference in overall job

Page 45
satisfaction, stress, job turnover or staff turnover between the stated models of care. In regards to
absenteeism and burnout none of the identified studies addressed these outcomes in terms of the two
models of care indicating a gap in current research. It is known that these factors have significant
implications for workplaces in regards to costs associated with replacement of staff to cover the
absenteeism or providing staff counselling services. There are also implications associated with an
employee’s absence from the workplace such as a loss of knowledge and skill which potentially
compromises patient care due to loss of expertise. Colleagues may be impacted due to increase in
workload as the absenteeism may not be replaced or is replaced with an inexperienced nurse. The
employee is also impacted through their overall sense of wellbeing and potential loss of income.
However what this review did show was that leadership, skill mix, defined nursing roles and staff retention
each have a greater influence on nurses’ wellbeing than the model of care being used. Findings from this
review may assist policy makers, nursing leaders and hospital executives in making an evidence-based
decision on which model of care to implement to achieve the best outcomes for nurse’s wellbeing.

King et al. (2015), published an editorial in the JBI Database of Systematic Reviews and Implementation
Reports 97 (Appendix VIII) which discussed factors other than nursing models, which may influence
nurses’ wellbeing and this included scope of practice, skill mix, patient care requirements, restructuring of
services and leadership. It is important that team members have a clear understanding of their scope of
practice to ensure role clarity, as highlighted in the Tran et al. 20 study which used the role conflict and
ambiguity scales developed by Rizzo et al.98 This study revealed that the higher the role ambiguity and
the lower the role clarity, the higher the levels of role conflict. There are also increasing advanced
registered nurse practitioner roles and extended enrolled nurse roles which increase these qualified
nurses’ scope of practice and which can create confusion. In Australia, it is reported that there is a lack of
insight into the roles of enrolled nurses and assistants in nursing, creating conflicts in regards to scope of
practice, which can lead to bullying and miscommunication regarding workloads and responsibilities.
Ultimately this can affect the quality of nursing care.33 Nurses need to be aware of their own scope of
practice and that of their colleagues, and this is the case for all models of care.

Job satisfaction, stress, burnout, absenteeism and nursing turnover all have financial implications for
nursing staff, patients and organizations due to costs associated with employing and training new staff,
replacing absent staff, costs of work cover associated with leave, and management of burnout and
stress-related illness. The loss of experienced nurses can negatively impact not only the team but also
patient care and outcome.

4.1.2 Nursing Models and Patient Care

Patient outcomes are not the focus of this review; however various studies have focused on the effects of
Page 46
the model of care, registered nurse staffing, increased nursing hours and patient turnover on patient
outcomes.37,99-104 One of the included studies78 identified a total patient care model as providing greater
client care than a team nursing model on the client care effectiveness scale. The number of patients
which a nurse cares for can affect their job satisfaction. As Hairr et al.96 discussed, if nurses have a
reduced number of patients to care for, they will have greater job satisfaction which will equate to better
patient outcomes.

The cost of the nursing and patient care requirements increasingly define which model of care is chosen.
Patient acuity needs to be considered when reviewing staffing requirements and balance the increasing
focus by management on staff costs. For example increased nursing hours per day have been linked to
decreased sepsis, shock and rates of pneumonia102 and can be attributed to better patient outcomes.104
The number of patients that nurses care for is also a significant factor and can cause an increase in
patient mortality, failure to rescue, decrease in quality of care and a decline in patient safety if there is a
decrease in nursing staff numbers to care for patients.103 The clinical implications that the different
nursing models have on patient outcomes have been addressed in the literature.37 As highlighted above
the model of care can impact on patient outcomes, however patients are usually unaware as to what
model of care is being used to organize the nursing work.105

The community and patients are now more aware and more involved in healthcare decisions, and
continue to expect more from the health care system. Consumers want to be involved in decision
making, they are aware of the issues in healthcare that affect them and will drive and insist on reform. 106
Therefore from a nursing perspective we need to ensure that the model of care meets the consumer’s
needs, to ensure that they are fully informed and involved in their care, but also ensures the wellbeing of
nurses.

4.1.3 Terminology and Methodological Tools

The review identified that quantitative studies need to have clear terminology to enable differentiation
between the various nursing models to ensure comparability between studies. This has previously been
identified as issues impacting on models of care research.19,31 This was a significant challenge in
conducting the review, not only were there inconsistencies in the definitions there were also combined
models which were ill-defined, making it difficult to compare outcomes. The issue with terminology
regarding nursing models was highlighted in a study by Minnick et al. 2007, which reviewed 40 random
US hospitals and found that none of the traditional models of care were implemented on the units to a
point where they could be specifically identified.107

The review demonstrated that there needs to be consistency in study designs and tools used to measure
aspects of staff wellbeing to enable reliable data extraction and synthesis. Difficulties with measurement
Page 47
tools was also identified in a systematic review on absenteeism which identified a “major inconsistency
across research on nursing absenteeism is around the measurement of this behavior.”47(p.107) The
authors describe that in some studies researchers relied on estimates, while in others researchers used
actual absenteeism.47

The differences in the terminology, which describes nursing models and inconsistencies with the
measurement tools used to measure staff wellbeing has created difficulties in effectively comparing
studies. Nursing as a profession needs to establish consistent, agreed upon terminology for the nursing
models that organize nursing work. There is also a requirement to develop study methodologies which
use reliable tools to measure staff wellbeing. This will enable comparison of studies in the future to
inform future nursing practice on the most effective nursing care delivery model which supports staff
wellbeing.

4.1.4 Restructuring and ward design

The term model of care is used extensively and can be broadly defined as the way in which healthcare
services are delivered.108 Nursing models of care in an acute care setting have been described earlier in
this thesis as the delivery of care through the organization of work inclusive of how nurses communicate
with each other, and other health professionals, and how the work is coordinated and delivered.4 The
way care is delivered and organized can be dependent on the hospital environment and structure. Models
of care delivery need to be reviewed when hospitals are restructured, as a result of new constructions,
major redevelopments, realignment of services and organizational structures. The design of new
hospitals and redevelopments are often radically different from previous or existing hospital designs.
This may have significant implications for the way in which clinical care is delivered. The current trends in
Australia and internationally for new hospital constructions is a single patient room approach, as opposed
to multiple beds in an area.109 110

Potential advantages of a single room model include increased patient privacy, enhanced sleep for
patients, increased patient satisfaction, reduced infection rates and fewer interruptions for staff. 110
Potential disadvantages include decreased patient visibility, increase in falls, patients feeling isolated and
increased distances for staff to cover thus reducing direct patient care.110 The impacts on staff outcomes
include increased staffing level requirements, increase in RN skill mix, increase in staff stress and
increased risks to personal safety. Currently there is scarce available evidence on the associated costs,
in relation to patient and staff outcomes of single room accommodation models.109,110

Realignment of services is a way in which organizations attempt to be cost effective,27 and improve
healthcare outcomes by reducing inefficiencies. Regardless of the rationale for changes to services,
models of care need to be reviewed when reconfiguration, realignment and amalgamation of health care
Page 48
delivery services occurs. In the 1990’s, 57% of United States hospital executives reported that their
organizations had undergone restructuring, resulting in a reduction of staff in 90% of these hospitals and a
reduction in nursing skill-mix in 70% of the restructured hospitals.27 These reductions have a large
impact on the nursing workforce and nurses have adapted to these challenges through increasing scope
of nurses’ practice, implementing professional practice models and changing care delivery models.

4.1.5 Cost effective care

Tiedeman and Lookinland 2004, describe that there are varying views regarding costs of nursing
models.19 In one study the team nursing model was seen as an expensive model as there are more
nurses required to deliver the care, and was also less efficient as coordinating and delegating was seen to
reduce productive work time.19 This is contradictory to other studies which found that a total patient care
model and a primary nursing model were more expensive and other studies that demonstrated there is no
difference in the cost. 19 There is a need for further studies on models of care which include an economic
evaluation to determine the most cost effective model, with a focus on nursing outcomes in terms of
nurses’ wellbeing.

Nurses are the largest professional group in hospitals and therefore account for a large component of a
hospital’s workforce expenditure.111 As mentioned previously the nursing workforce is influenced by
many factors such as budgetary constraints, recruitment and retention of staff, workforce demographics
such as an ageing workforce and ever changing technologies and treatment advances. It is predicted
that there will be a shortage in nurses of up to 27%, or 109,000 nurses, in Australia if changes to education
and efficiencies in health care sector are not made.112 Nursing leaders and organizations need to ensure
that the current and future nursing workforce is equipped and adapted to meet these needs and that of the
community’s expectations to receive safe and effective care.

4.1.6 Professional practice models and Magnet®

This thesis has focused on nursing care delivery models rather than professional practice models,
however it is necessary to briefly discuss the concepts of professional practice models. Nursing care
delivery models are a system to manage and organize how nursing care is delivered, whereas
professional practice models set expectations for professional behaviors and clinical leadership, allow for
mutual goal setting and make patient care the priority for the multidisciplinary team.14 In addition they
provide clear direction to nursing practice which enables autonomous decision making and empowerment
of nurses’.15 Professional practice models have also enabled improved multidisciplinary communication,
consistent nursing care and improved patient outcomes.113,114 Professional practice models and
frameworks are continuing to evolve as the science of nursing builds its knowledge base. 14 A practice

Page 49
model ‘reflects nursing values and the culture of an organization. The dominant attributes shared
among models and featured in Magnet® organizations include nursing autonomy; empowerment; and
cost-effective, quality care.’14 (p.16)

The concept of Magnet® organizations, developed in the United States of America in the1980’s these
organizations demonstrated an ability to attract and retain nurses, which later formed the successful
characteristics for Magnet® recognition.115 Magnet® recognition requires health care organizations to
apply to the American Nurses Credentialing Center (ANCC). Organizational nursing leaders need to
adopt a professional practice model with shared governance to provide the necessary evidence of the
required outcomes needed for Magnet® designation.116,117 As of March 2016 there were 433
Magnet®-designated organizations, with three in Australia.118 There are fourteen forces of
magnetism, which are organized into five components which consist of “transformational leadership,
structural empowerment, exemplary professional practice, (new knowledge, innovation and
improvement), empirical quality results.”116(p.136) Leadership is fundamental to the success of
professional practice models as they are able to communicate the vision, values and ensure
accountability of team members.

4.1.7 Nursing leadership

Leadership is fundamental in all professional fields. In nursing there are various forms of nursing leaders
and they are situated throughout the healthcare system and influence healthcare policy.119 This
discussion however will focus on nursing leaders in the acute care sector, in particular clinical leadership,
and will briefly discuss executive leadership. Clinical nurse leadership for the purpose of this thesis is
leadership at the direct patient care level.120 It is also important to note that there are informal nursing
leaders for example, team leaders who often have a great influence on the ward and often lead the team
when formal leaders are not present.119,121 To implement or change the model of care these informal
leaders perform a significant role in influencing and ensuring the success of the change, and it is
imperative for a clinical leader to identify who these staff are. Nursing executive leaders provide
organizational direction and they influence the workforce, scope of nursing practice and the patient
experience at a strategic level.122 Nursing’s executive leaders also provide professional leadership to
nursing leaders and nurses, are involved with resource management (both workforce and financial) and
set the standard for care and provide governance. This role includes engaging with internal and external
stakeholders such as patients, caregivers, government officials and educational institutions and these
connections can assist in identifying and implementing models of care.119

Clinical nurse leadership has been described by Stanley 2006 as “a clinician who is an expert in their field,
and who, because they are approachable, effective communicators and empowered, are able to act as a

Page 50
role model, motivating others by matching their values and beliefs about nursing and care to their
practice.”123 (p.111) It is important that clinical nurse leaders possess these qualities as they need to be
able to communicate with patients, families, nursing staff, the multidisciplinary team and management.
They need to be good clinicians to ensure that they can recognise gaps in patient care and any identify
system issues or risk concerns. 119 The ability to role model best practice is a necessity to this role, as is
the need to promote a positive work environment. Creating a positive work environment however is a
shared responsibility across the organization and involves all staff.119

Clinical nursing leaders need to influence the work environment by managing staff and ensuring staff are
equipped with the appropriate skills and knowledge to provide quality patient care. There may be a
requirement for a clinical nurse leader to change the model of care due to workforce issues, restructuring,
financial implications or changes to the professional practice model. Wolf and Greenhouse 2007
discuss, when developing a care delivery model for the future it is not necessary to start from the
beginning; we can learn from the past and from scientific evidence, and include these into our planning.106
To change the model of care requires strong leadership and management support.124

Hayman et al. 2006 discuss in their study that there was negativity in changing the model of care pre- and
post-implementation and that this was largely due to a lack of involvement and communication from
managers with the change process.125 Nursing staff engagement is pivotal in successfully changing the
model of care. This is further supported by Cornelissen 2008 who describes that when employees are
involved in decision-making and are able to exert some control over their working life then they connect
better with the organization and are more committed.126

Patient clinical indicators, patient safety and quality improvement initiatives need to be at the forefront of
nursing leader’s decision making when determining the appropriate care model. Clinical nursing leaders
are required to monitor and manage workforce issues such as absenteeism, turnover, stress, work cover
and staff performance. In summary, nursing clinical leaders need to communicate with a wide variety of
stakeholders, manage budgets in a fiscally responsible manner, be abreast of clinical advancements in
healthcare and provide clear leadership.

4.2 Limitations of the review

Challenges faced in conducting the systematic review included a lack of consistency with terminology and
a lack of consistent interpretation of the various nursing models in the literature. This may have resulted
in relevant studies not being identified in the search or being excluded from the review. The review only
identified three studies which met the inclusion criteria, and there was inconsistency in the study designs
and each was limited by small and differing sample sizes. One study18 had 221 participants, the second
study20 had 125 participants and the final study,78 78 participants. In addition there was attrition of
participants and a lack of randomization. No studies were found that addressed the outcomes of staff
Page 51
burnout and absenteeism. Only studies published in English were sought, and this may have excluded
potentially relevant studies published in other languages. Results of the review may be affected by the
fact that only studies published in English where included in the review and two were conducted in
Australia.18,20

4.3 Conclusion
Due to the limited number of quantitative studies identified for inclusion in the systematic review, whether
a team nursing model is more effective than a total patient care model on staff wellbeing when organizing
nursing work in acute care settings could not be determined. It can be concluded from the results of the
review that a team nursing model may be a beneficial model to support novice, inexperienced nursing
staff. In addition the team nursing model is appropriate when there is a lower registered nurse skill mix;
however there needs to be clarity in roles and responsibilities for each team member to ensure
satisfaction with co-workers. Nursing turnover may be reduced in team nursing model wards compared
with total patient care model wards although this result was not statistically significant. Team nursing
model and total patient care models do not significantly influence nurse job satisfaction, stress levels or
staff turnover. It was not possible to ascertain if models of care affect absenteeism or burnout due to there
being no identified studies that addressed these outcomes.

In summary, future research should focus on staff wellbeing and whilst models of care should be included
in the discussion it is more likely from the evidence obtained in the systematic review and this thesis that
leadership, skill mix, patient acuity, nurse to patient ratios, experience level, organizational culture and
governance have a greater impact on nurse’s wellbeing. There is a need for the national and
international nursing profession to reach agreement on a range of definitions and measurement for
nursing performance and wellbeing that will empower the profession to ensure that it is positioned to
determine safe staffing levels, effective models of care and practice changes and respond appropriately to
budgetary measures imposed on the system.

4.4 Implications for practice

Based on the evidence reviewed, it is recommended that the following be considered by managers and
organizations when considering either a team nursing model or a total patient care model to organize
nursing work (JBI Grades of recommendations used – Appendix IX):

 Caution should be taken when evaluating which model of care is appropriate and the decision
needs to include staff experience level and staff skill mix. (Grade B)
 A team nursing model may be the most appropriate nursing care model to support novice nurses,
in particular, new graduate nurses. (Grade B)
 There needs to be clearly defined nursing roles to decrease role ambiguity when working in a
Page 52
 team nursing model to ensure job satisfaction with co-workers. (Grade B)
 Nursing leadership is fundamental to the successful execution of nursing care delivery models.
(Grade B)

4.5 Implications for research

The systematic review demonstrated that there is limited quantitative research in this topic area.

 To allow for future comparison and research to occur at a national and international level, there
needs to be consistent agreed upon terminology for describing the models of care and consistent
tools as measures. There needs to be detailed descriptions of how each model is defined,
including hybrid models.
 There needs to be further randomized and pseudo-randomized controlled studies conducted to
explore models of care and the impact each model has on nurses’ wellbeing, in particular, studies
addressing burnout and absenteeism.
 Small sample sizes, different study designs and poor response rates to surveys resulted in an
inability to ascertain the most effective model of care based on the evidence presented in the
studies due to limited statistical analysis. Future research should seek to include larger sample
sizes and to mitigate attrition.
 It would be beneficial for future studies on models of care to include an economic analysis to fully
inform policy and practice.

Page 53
References

1. King AS, Long L, Lisy K. Effectiveness of team nursing compared with total patient care on staff
wellbeing when organizing nursing work in acute care ward settings: a systematic review
protocol. The JBI Database of System Rev and Implement Rep. 2014; 12(1):59-73.
2. King AS, Long L, Lisy K. Effectiveness of team nursing compared with total patient care on staff
wellbeing when organizing nursing work in acute care ward settings: a systematic review
protocol. Prospero. 2014.
3. King AS, Long L, Lisy K. Effectiveness of team nursing compared with total patient care on staff
wellbeing when organizing nursing work in acute care wards: a systematic review. JBI Database
System Rev and Implement Rep. 2015; 13(11):128-68.
4. Fowler J, Hardy J, Howarth T. Trialing collaborative nursing models of care: the impact of change.
Aust J Adv Nurs. 2006; 23(4):40-6.
5. Dubios C, D'Amour D, Tchouaket E, Rivard M, Clarke S, Blais R. A taxonomy of nursing care
organization models in hospitals. BMC Health Serv Res. 2012; 12(286). [cited 24/4/2016]
Available from: www.biomedcentral.com/1472-6963/12/286
6. Tourville C, Ingalls K. The Living Tree of Nursing Theories. 2003; [cited 25/4/2016].
7. McCrae N. Whither Nursing Models? The value of nursing theory in the context of
evidence-based practice and multidisciplinary health care. J Adv Nursing. 2012; 68(1):222-9.
8. Alligood MR. Introduction to Nursing Theory: Its History, Significance, and Analysis. In: Alligood
MR, Tomey AM, editors. Nursing Theorists and Their Work. 7th ed. Mosby Inc. 2010; p. 3-15.
9. Porter S. Nightingale's realist philosophy of science. Nurs Philos. 2001; 2(1):14-25.
10. Fortin J. Human Needs and Nursing Theory. Nursing Theories: Conceptual and Philosophical
Foundations. 2nd ed. New York: Springer Publishing Company; 2006.
11. Kim H. Synopsis of Selected Nursing Theories and Conceptual Models. Nursing Theories:
Conceptual and Philosophical Foundations. 2nd ed. New York: Springer Publishing Company;
2006.
12. Benner PE. From novice to expert: excellence and power in clinical nursing practice. Menlo Park,
California: Addison-Wesley Pub. Co, Nursing Division; 1984.
13. Benner PE. From Novice to Expert. Am J Nurs. 1982; 82(3). [cited 25/4/2016] Available from:
https://www.medicalcenter.virginia.edu/therapy-services/3%20-%20Benner%20-%20Novice%2
0to%20Expert-1.pdf
14. Chamberlain B, Bersick E, Cole D, Craig J, Cummins K, Duffy M, et al. Practice models : A
concept analysis. Nurs Manage. 2013; [cited 25/4/2016]. Available from:
http://www.njha.com/media/278946/NursingMgmt1013.pdf
15. Pearson A, Vaughan B, FitzGerald M. Nursing Models for Practice. 3rd ed. Wolfaard S, editor.
UK: Butterworth-Heinemann Elsevier Limited; 2005.
16. Pearson A, FitzGerald M, Walsh K, Long L, Borbasi S, Heinrich N. Patterns of Nursing Care. In:
Nursing DoC, editor. The University of Adelaide: Department of Clinical Nursing; 1999; p. 1-128.
17. Shields LA. The Parent-Staff Interaction Model of Pediatric Care. J Pediatr Nurs. 2002;
17(6):442-9.
Page 54
18. Fairbrother G, Jones A, Rivas K. Changing model of nursing care from individual patient
allocation to team nursing in the acute inpatient environment. Contemp Nurse. 2010;
35(2):202-20.
19. Tiedeman ME, Lookinland S. Traditional models of care delivery: what have we learned? J Nurs
Adm. 2004; 34(6):291-7.
20. Tran DT, Johnson M, Fernandez R, Jones S. A shared care model vs. a patient allocation model
of nursing care delivery: comparing nursing staff satisfaction and stress outcomes. Int J Nurs
Pract. 2010; 16(2):148-58.
21. Chiarella M, Lau C. First report on the models of care project. NSW Health. 2006; p.1-32.
22. Ferguson L, Cioffi J. Team nursing: experiences of nurse managers in acute care settings. Aust J
Adv Nurs. 2011; 28(4):5-11.
23. Mäkinen A, Kivimäki M, Elovainio M, Virtanen M, Bond S. Organization of nursing care as a
determinant of job satisfaction among hospital nurses. J Nurs Manage. 2003; 11(5):299-306.
24. Hayman B, Wilkes L, Cioffi J. Change process during redesign of a model of nursing practice in a
surgical ward. J Nurs Manage. 2008; 16(3):257-65.
25. Sellick KJ, Russell S, Beckmann JL. Primary nursing: an evaluation of its effects on patient
perception of care and staff satisfaction. Int J Nurs Stud. 2003; 40(5):545-51.
26. Australia’s Health Workforce. Nurses in focus. In: Australia HW, editor. Adelaide: Health
Workforce Australia; 2013.
27. Aiken LH, Clarke SP, Sloane DM, Sochalski JA. An international perspective on hospital nurses'
work environments: the case for reform. Policy Polit Nurs Pract. 2001; 2(4):255-63.
28. Needleman J, Buerhaus P. Nurse staffing and patient safety: current knowledge and implications
for action. Int J Qual Health Care. 2003; 15(4):275-7.
29. Lang TA, Hodge M, Olson V, Romano PS, Kravitz RL. Nurse-patient ratios: a systematic review
on the effects of nurse staffing on patient, nurse employee, and hospital outcomes. J Nurs Adm.
2004; 34(7/8):326-37.
30. Butler M, Collins R, Drennan J, Halligan P, O’Mathúna DP, Schultz TJ, et al. Hospital nurse
staffing models and patient and staff-related outcomes. Cochrane Database Syst Rev. 2011; 7.
31. Fernandez R, Johnson M, Tran DT, Miranda C. Models of care in nursing: a systematic review.
International journal of evidence-based healthcare. 2012; 10(4):324-37.
32. Adams A, Bond S. Staffing in acute hospital wards: part 1. The relationship between number of
nurses and ward organizational environment. J Nurs Manage. 2003; 11(5):287-92.
33. Eagar SC, Cowin LS, Gregory L, Firtko A. Scope of practice conflict in nursing: A new war or just
the same battle? Contemp Nurse. 2010; 36(1/2):86-95.
34. McGillis Hall L. Staff mix models: complementary or substitution roles for nurses. Nurs Adm Q.
1997; 21(2):31-9.
35. Everhart D, Neff D, Al-Amin M, Nogle J, Weech-Maldonado R. The Effects of Nurse Staffing on
Hospital Financial Performance: Competitive Versus Less Competitive Markets. Health Care
Manage Rev. 2013; 38(2):146-55.

Page 55
36. Twigg D, Duffield C. A review of workload measures: a context for a new staffing methodology in
Western Australia. Int J Nurs Stud. 2009; 46(1):132-40.
37. McGillis Hall L, Doran D, Pink GH. Nurse staffing models, nursing hours, and patient safety
outcomes. J Nurs Adm. 2004; 34(1):41-5.
38. Duffield C, O'Brien-Pallas L. The causes and consequences of nursing shortages: a helicopter
view of the research. Aust Health Rev. 2003; 26(1). [cited 24/04/2016]. Available from:
www.publish.csiro.au/?act=view_file&file_id=AH030186.pdf
39. Walker K, Donoghue J, Mitten-Lewis S. Measuring the impact of a team model of nursing practice
using work sampling. Aust Health Rev. 2007; 31(1):98-107.
40. Wiggins MS. The partnership care delivery model: an examination of the core concept and the
need for a new model of care. J Nurs Manage. 2008; 16(5):629-38.
41. Australian Nursing Midwifery Council. National framework for the development of
decision-making tools for nursing and midwifery practice. ACT, Australia: ANMC. 2007; [cited
04/03/2015]. Available from: http://www.anmc.org.au
42. Australian Nursing Midwifery Council. Delegation and Supervision for Nurses and Midwives.
ACT, Australia: ANMC. 2007; [cited 04/03/2015]. Available from: http://www.anmc.org.au
43. Lu H, While AE, Louise Barriball K. Job satisfaction among nurses: a literature review. Int J Nurs
Stud. 2005; 42(2):211-27.
44. Jennings BM. Work Stress and Burnout Among Nurses: Role of the Environment and Working
Conditions. In: RG H, editor. Patient Safety and Quality: An Evidence-Based Handbook for
Nurses. Rockville. 2008; [cited 14/07/2013]. Available from:
http://www.ncbi.nlm.nih.gov/books/NBK2668/
45. OED Online: Oxford University Press; nd. Oxford English Dictionary Online.
46. Poghosyan L, Clarke S, Finlayson M, L. A. Nurse burnout and quality of care: cross-national
investigation in six countries. Res Nurs Health. 2010; 33(4):288-9.
47. Daouk-Oyry L, Anouze A, Otaki F, Dumit N, Osman I. The JOINT model of nurse absenteeism
and turnover: A systematic review. Int J Nurs Stud. 2014; 21:93-110.
48. Davey MM, Cummings G, Newburn-Cook CV, Lo EA. Predictors of nurse absenteeism in
hospitals: A systematic review. J Nurs Manage. 2009; 17(3):312-30.
49. Tripathi M, Mohan U, Tripathi M, Verma R, Masih L, Pandey HC. Absenteeism among nurses in a
tertiary care hospital in India. Natl Med J India. 2010; 23(3):143-6.
50. Buchan J, Aiken L. Solving nursing shortage: a common priority. J Clin Nursing. 2008;
17(24):3262-8.
51. Hayes LJ, O'Brien-Pallas L, Duffield C, Shamian J, Buchan J, Hughes F, et al. Nurse turnover: A
literature review - An update. Int J Nurs Stud. 2012; 49(7):887-905.
52. The Joanna Briggs Institute. 2014. Joanna Briggs Institute Reviewers' Manual 2014 Edition.
Australia: The Joanna Briggs Institute; 2014.
53. Hemingway P, Brereton N. What is a systematic review? In: Medicine EB, editor. second ed:
Evidence Based Medicine; 2009.

Page 56
54. Grant M, J., Booth A. A typology of reviews: an analysis of 14 review types and associated
methodologies. Health Info Libr J. 2009; 26(2):91-108.
55. Lockwood C, Sfetcu R, Oh GE. Synthesizing Quantitative Evidence. Lippincott Williams Wilkins
Medical. 2011; [cited 03/01/2016].
56. Jordan Z, Donnelly P, Pittman P. A short history of a BIG idea: The Joanna Briggs Institute
1996-2006. Melbourne: Ausmed Publications; 2006.
57. Annemans L. Health economics for non-economists. An introduction to the concepts, methods
and pitfalls of health economic evaluations: Gent, Academia Press. 2008; [cited 12/03/2016].
58. O'Rourke K. An historical perspective on meta-analysis: dealing quantitatively with varying
results. J R Soc Med. 2007; 100:579-82.
59. Glass GV. Primary, secondary, and meta-analysis of research. Educ Res. 1976; 5(10):3-8.
60. Mertens DM. Research and Evaluation and Education and Psychology. SAGE Publications, Inc.
2015.
61. Guba E, Lincoln Y. Competing paradigms in qualitative research. In: Denzin N, Lincoln Y, editors.
Handbook of Qualitative Research. Thousand Oaks: Sage Publications. 1994. p.105-17.
Available from:
https://www.uncg.edu/hdf/facultystaff/Tudge/Guba%20&%20Lincoln%201994.pdf
62. Grant BM, Giddings LS. Making sense of methodologies: A paradigm framework for the novice
researcher. Contemp Nurse. 2002; 13(1):10-28.
63. Scotland J. Exploring the Philosophical Underpinnings of Research: Relating Ontology and
Epistemology to the Methodology and Methods of the Scientific, Interpretive, and Critical
Research Paradigms. English Language Teaching [Internet]. 2012; 5(9). [cited 17/4/2016].
Available from: www.ccsenet.org/journal/index.php/elt/article/viewFile/19183/12667
64. Popay J, Roberts H, Sowden A, Petticrew M, Arai L, Rodgers M, et al. Guidance on the Conduct
of Narrative Synthesis in Systematic Reviews : ESRC Methods Programme: Lancaster
University. 2006. Available from:
https://www.researchgate.net/publication/233866356_Guidance_on_the_conduct_of_narrative_
synthesis_in_systematic_reviews_A_product_from_the_ESRC_Methods_Programme
65. Dixon-Woods M, Agarwal S, Young B, Jones D, A S. Integrative approaches to qualitative and
quantitative evidence. England: NHS Health Development Agency; 2004.
66. Parker M. False dichotomies: EBM, clinical freedom, and the art of medicine. Med Humanit.
2005; 31:23-30.
67. Shah H, Chung K. Archie Cochrane and His Vision for Evidence-Based Medicine. Plast Reconstr
Surg. 2009; 124(3). [cited 15/04/2016].
68. Sur R, Dahm P. History of Evidence-Based Medicine. Indian J Urol. 2011; 27(4). [cited
15/4/2016].
69. Sackett DL, Rosenberg W, Gray J, Haynes B, Richardson WS. Evidence based medicine: what it
is and what it isn't. BMJ. 1996; 312:71-2.
70. Titler MG. The Evidence for Evidence-Based Practice Implementation. In: Hughes RG, editor.
Patient Safety and Quality: An Evidence-Based Handbook for Nurses. US: Rockville (MD):

Page 57
 Agency for Healthcare Research and Quality. 2008; Apr. [cited 27/7/2016]. Available from:
http://www.ncbi.nlm.nih.gov/books/NBK2659/
71. International Council of Nurses 2014. Closing the Gap: From Evidence to Action. Switzerland.
2012. [cited 27/07/2016]. Available from:
http://www.icn.ch/images/stories/documents/publications/ind/indkit2012.pdf
72. Mahid SS, Hornung CA, Minor KS, Turina M, Galandiuk S. Systematic reviews and meta-analysis
for the surgeon scientist. Br J Surg. 2006; 93. [cited 20/1/2016]
73. The Joanna Briggs Institute. Joanna Briggs Institute Reviewers' Manual 2014 edition/
Supplement: The Joanna Briggs Institute. 2014.
74. Tricco AC, Tetzlaft T, Sampson M, Fergusson D, Cofgo E, Horsley T, et al. Few systematic
reviews exist documenting the extent of bias: a systematic review. J Clin Epidemiol. 2008;
61:422-34.
75. Hayes LJ, O’Brien-Pallas L, Duffield C, Shamian J, Buchan J, Hughes F, et al. Nurse turnover: A
literature review. Int J Nurs Stud. 2006; 43(2):237-63.
76. O'Brien-Pallas L, Griffin P, Shamian J, Buchan J, Duffield C, Hughes F, et al. The impact of nurse
turnover on patient, nurse, and system outcomes: A pilot study and focus for a multicenter
international study. Pol. Polit. Nurs. Pract. 2006; 7(3):169-79.
77. The Australasian Faculty of Occupational Medicine. Workplace attendance and absenteeism.
Royal College of Physicians. 1999; 1-64.
78. Wells J, Manuel M, Cunning G. Changing the model of care delivery: nurses' perceptions of job
satisfaction and care effectiveness. J Nurs Manage. 2011; 19(6):777-85.
79. Fairbrother G, Jones A, Rivas K. Development and validation of the Nursing Workplace
Satisfaction Questionnaire (NWSQ). Contemp Nurse. 2009; 34(1):10-8.
80. Ironson G, Smith P, Brannick M, Gibson W, Paul K. Construction of the job in general scale: a
comparison of global, composite and specific measures. J Appl Psychol. 1989; 74:193-200.
81. Balzer W, Kihm J, Smith P. Users' Manual for the Job Descriptive Index (JDI; 1997 version) and
the Job in General Scales. Ohio, USA: Bowling Green State University; 2000.
82. Stamps P. Nurses and Work Satisfaction: An Index for Measurement. 2nd ed. Chicago, Illinois:
Health Administration Press; 1997.
83. Smith P, Balzer W, Ironson G. Development and Validation of the Stress in General (SIG) scale.
Paper presented at: The 7th Annual Society for Industrial and Organizational Psychology.
Montreal, QC.1992.
84. Lyons T. Role clarity, need for clarity, satisfaction, tension, and withdrawal. Organ Behav Hum
Perf. 1971; 6:99-110.
85. Adams A, Bond S, Hale CA. Nursing organizational practice and its relationship with other
features of ward organization and job satisfaction. J Adv Nursing. 1998; 27(6):1212-22.
86. Adams A, Bond S. Staffing in acute hospital wards: part 2. Relationships between grade mix, staff
stability and features of ward organizational environment. J Nurs Manage. 2003; 11(5):293-8.
87. McGillis Hall L, Doran D. Nurses' perceptions of hospital work environments. J Nurs Manage.
2007; 15(3):264-73.

Page 58
88. Sjetne IS, Veenstra M, Ellefsen B, Stavem K. Service quality in hospital wards with different
nursing organization: nurses' ratings. J Adv Nursing. 2009; 65(2):325-36.
89. Kivimaki M, Makinen A, Elovainio M, Vahtera J, Virtanen M, Firth-Cozens J. Sickness absence
and the organization of nursing care among hospital nurses. Scand J Work Environ Health. 2004;
30(6):468-76.
90. Vlerick P. Burnout and work organization in hospital wards: a cross-validation study. Work Stress.
1996; 10(3):257-65.
91. Tourangeau AE, White P, Scott J, McAllister M, Giles L. Evaluation of a partnership model of care
delivery involving registered nurses and unlicensed assistive personnel. Can J Nurs Leadersh.
1999; 12(2). [cited 21/4/2014]. Available from:
http://onlinelibrary.wiley.com/o/cochrane/clcentral/articles/227/CN-00326227/frame.html
92. Cioffi J, Ferguson L AM. Team nursing in acute care settings: nurses' experiences. Contemp
Nurse. 2009; 33(1):2-12.
93. Kangas S, Kee CC, McKee-Waddle R. Organizational factors, nurses' job satisfaction, and
patient satisfaction with nursing care. J Nurs Adm. 1999; 29(1):32-42.
94. Tomey AM. Nursing leadership and management effects work environments. J Nurs Manage.
2009; 17(1):15-25.
95. Spence Laschinger HK, Leiter MP. The impact of nursing work environments on patient safety
outcomes: the mediating role of burnout/engagement. J Nurs Adm. 2006; 36(5):259-67.
96. Hairr DC, Salisbury H, Johannsson M, Redfern-Vance. Nurse Staffing and the Relationship to
Job Satisfaction and Retention. Nurs Econ. 2014; 32(142-147).
97. King AS, Long L, Lisy K. Can nurses' wellbeing be linked to models of care or other influences?
JBI Database System Rev and Implement Rep. 2015; 13(11):1-3.
98. Rizzo JR, House RJ, Lirtzman SI. Role conflict and ambiguity in complex organizations. Adm Sci
Q. 1970; 6:99-110.
99. Rafferty AM, Clarke SP, Coles J, Ball J, James P, McKee M, et al. Outcomes of variation in
hospital nurse staffing in English hospitals: cross-sectional analysis of survey data and discharge
records. Int J Nurs Stud. 2007; 44(2):175-82.
100. Mcgillis Hall L, Doran D, Baker GR, Pink GH, Sidani S, O'Brien-Pallas L, et al. Nurse staffing
models as predictors of patient outcomes. Med Care. 2003; 41(9):1096-109.
101. Aiken LH, Clarke SP, Sloane DM, Sochalski J, Silber JH. Hospital nurse staffing and patient
mortality, nurse burnout, and job dissatisfaction. J Am Med Assoc. 2002; 288(16):1987-93.
102. Duffield C, Diers D, O'Brien-Pallas L, Aisbett C, Roche M, King M, et al. Nursing staffing, nursing
workload, the work environment and patient outcomes. Appl Nurs Res. 2011; 24(4):244-55.
103. Pearson A, Pallas LO, Thomson D, Doucette E, Tucker D, Wiechula R, et al. Systematic review of
evidence on the impact of nursing workload and staffing on establishing healthy work
environments. Int J Evid Based Healthcare. 2006; 4(4):337-84.
104. Needleman J, Buerhaus P, Mattke S, Stewart M, Zelevinsky K. Nurse-staffing levels and the
quality of care in hospitals. New Engl J Med. 2002; 346(22):1715-22.
105. Gullick J, Shepherd M, Ronald T. The effect of an organisational model on the standard of care.
Nurs Times. 2004; 100(10):36-9.
Page 59
106. Wolf GA, Greenhouse PK. Blueprint for design: Creating models that direct change. J Nurs Adm.
2007; 37(9):381-7.
107. Minnick AF, Mion LC, Johnson ME, Catrambone C. How unit level nursing responsibilities are
structured in US hospitals. J Nurs Adm. 2007; 37(10):452-8.
108. Agency for Clinical Innovation. Understanding the process to develop a model of care. New
South Wales, Australia. 2013; p. 1-20.
109. Chaudhury H, Mahmood A, Valente M. The Use of Single Patient Rooms versus Multiple
Occupancy Rooms in Acute Care Environments CHER. 2005. [cited 30/04/2016]. Available from:
https://www.healthdesign.org/chd/research/use-single-patient-rooms-versus-multiple-occupanc
y-rooms-acute-care-environments
110. Maben J, Griffiths P, Penfold C, Simon M, Pizzo E, Anderson J, et al. Evaluating a major
innovation in hospital design: workforce implications and impact on patient and staff experiences
of all single room hospital accommodation. NIHR Journals Library. 2015; 3(3).
111. Wong F, Liu H, Wang H, Anderson D, Seib C, Molasiotis A. Global Nursing Issues and
Developments: Analysis of World Health Organization Documents. J Nurs Scholarsh. 2015;
47(6):574-83.
112. Australia’s Health Workforce. Health Workforce 2025 Doctors, Nurses and Midwives. Adelaide.
2012; p.1-197.
113. Harwood L, Ridley J, Lawrence-Murphy JA, Spence-Laschinger HK, White S, Bevan J, et al.
Nurses' perceptions of the impact of a renal nursing professional practice model on nursing
outcomes, characteristics of practice environments and empowerment -- Part I. CANNT Journal.
2007; 17(1):22-9.
114. Harwood L, Ridley J, Lawrence-Murphy JA, Spence-Laschinger HK, White S, Bevan J, et al.
Nurses' perceptions of the impact of a renal nursing professional practice model on nursing
outcomes, characteristics of practice environments and empowerment--Part II. CANNT Journal.
2007; 17(2):35-43.
115. Joyce J, Crookes P. Developing a Tool to Measure 'Magnetism' in Australian Nursing
Environments. Aust J Adv Nurs. 2007; 25(1):17-23.
116. Tinkham MR. Pursuing Magnet Designation: Choosing a Professional Practice Model. AORN J.
2013; 97(1):136-9.
117. Jost SG, Rich VL. Transformation of a nursing culture through actualization of a nursing
professional practice model. Nurs Adm Q. 2010; 34(1):30-40.
118. American Nurses Credentialing Center. Magnet Recognition Model. 2016 [cited 1/05/2016].
Available from:
http://www.nursecredentialing.org/Magnet/ProgramOverview/New-Magnet-Model.aspx
119. Australian College of Nursing. Nurse Leadership. 2015. Available from:
https://www.acn.edu.au/sites/default/files/leadership/ACN_Nurse_Leadership_White_Paper_FI
NAL.pdf
120. Willcocks SG. Exploring leadership effectiveness: nurses as clinical leaders in the NHS Leadersh
Health Serv. 2012; 25(1):8-19.
121. Downey M, Parslow S, Smart M. The hidden treasure in nursing leadership: informal leaders. J
Nurs Manag. 2011; 19(4):517-21.
Page 60
122. White J. Reflections on strategic nurse leadership. J Nurs Manage. 2012; 20(7):835-7.
123. Stanley D. Clinical leadership. Recognizing and defining clinical nurse leaders. Br J Nurs. 2006;
15(2):108-11.
124. Manojlovich M, Laschinger H. The Nursing Worklife Model: extending and refining a new theory.
J Nurs Manage. 2007; 15(3):256-63.
125. Hayman B, Cioffi J, Wilkes L. Redesign of the model of nursing practice in an acute care ward:
nurses' experiences. Collegian. 2006; 13(1):31-6.
126. Cornelissen J. Corporate Communications: A Guide to Theory and Practice. Sage. 2011.

Page 61
Appendix I: Systematic review protocol

Review title

Effectiveness of team nursing compared with total patient care on staff wellbeing when organizing nursing
work in acute care ward settings: a systematic review protocol

Reviewers
Allana King RGN, BNurs, MHlthAdmin, CFJBI, MSc candidate1, 2
A/Prof Lesley Long, AM PhD, MHA, Ba Nsg, RGN2
Dr Karolina Lisy BSc (Hons) PhD, Research Fellow2

1. Ward Q5, Royal Adelaide Hospital, North Terrace, Adelaide, South Australia 5000,
[email protected]

2. The Joanna Briggs Institute/School of Translational Health Science, Faculty of Health Sciences,
University of Adelaide, South Australia 5005

Review question/objective

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

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

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

Provision of care in an organisational setting, specifically at a clinical services unit level

(ward)…Presents the structural and contextual dimensions of nursing practice...Governs the
manner in which nurses organise work groups, communicate with work group members and with
other disciplines, interact, make decisions, and create an environment within which nursing care
is delivered among care providers, and specify communication and coordination patterns
necessary to support care.1 (pp. 40-41)

There are four predominant traditional nursing care models described in the literature to organize nursing

Page 62
work: team nursing, total patient care (also known as patient allocation), task method, and primary
nursing.2 In recent years there has been the emergence of other models as well as various combinations
of different models. In Australia, individual total patient care is the main model utilized in acute care
hospitals.3 Team nursing is also a prominent care delivery model used in general ward settings whereas
task allocation and primary nursing is not as commonly utilized. The model of nursing selected is
dependent on nursing resources and patient care requirements. Tiedeman and Lookinland, 2004 state
that models “differ in clinical decision making, work allocation, communication, and management, with
differing social and economic forces driving the choice of model.”4 (p 291)

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

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

The model of care is critical in defining the nursing work environment. Nursing work environments are
complex; prioritising work is essential and the need to reprioritise nursing workloads on a daily basis is
Page 63
often necessary. Research has shown that nursing work environments and also job satisfaction are
influenced by organizational structures, leadership, autonomy, models of care, multidisciplinary
collaboration and interpersonal relationships.5,14 Ward areas may adapt different models of care due to
the knowledge and skill level of staff or to influence teamwork to increase job satisfaction. Organizations
need to manage within allocated resources and ensure that they have the most appropriate model to
support staff and ensure safe effective clinical outcomes. Regardless of the model of care, all nursing staff
are required to practice within their scope of practice and be aware of the scope of their colleagues’
practice. Confusion with scope of practice leads to conflict, inter-professional rivalry, and even bullying.15
Due to the global shortage of nurses and skill mix issues it is important to ensure the organizational model
in the clinical area utilizes the skills and experience of the available staff.

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

The purpose of this review will be to compare the effectiveness of team nursing and total patient care
through evaluating which model of care achieves greater staff wellbeing. Staff wellbeing will be measured
by staff outcomes in relation to staff satisfaction, turnover, absenteeism, stress levels and burnout. This
review will focus on the acute care hospital sector and in particular general ward settings. To avoid
potential duplication of the proposed review topic, searches of the Joanna Briggs Institute Library and The
Cochrane Library were undertaken. The search revealed a systematic review has recently been published
on this topic which looked at various models of care and the effects these models have on staff and patient
outcomes. In particular staff outcomes such as staff satisfaction, role clarity and absenteeism. The review
also looked at patient outcomes in terms of nurse sensitive indicators such as falls, medication errors and
infection rates. However, the proposed review, while replicating some of the outcome measures used in a
review by Fernandez R et al (2012), extends the outcomes to include turnover, stress and burnout and
narrows the focus to two models of care delivery. The purpose of replicating some of the outcome
measures of staff satisfaction and absenteeism is to extract a clear picture of the differences in the two
care models, team nursing and total patient care. There have been quantitative and qualitative reviews
conducted on nursing models and the effects on patient, organizational and staff related outcomes.11-13
but none narrowing the focus to these two models and their direct effect on staff wellbeing.

Finally, it is hoped that this quantitative review will assist in informing practice on these two care delivery
models: team nursing and total patient care, by establishing the effect that each model has on the nurses
Page 64
delivering them. This review will enable a greater understanding of the impact stress and burnout,
turnover rates, absenteeism and staff satisfaction have on staff wellbeing. In Australia, the Australian
Nursing and Midwifery Council outlines that nurses’ scope of practice encompasses activities such as
decision making, role and responsibility and function and the scope of practice which is legislated. 18 The
role of the registered nurse includes delegation and this requires an understanding of other team
member’s scope of practice, education level and experience. The reviewer is interested at a local level as
currently in Australia there are a number of new hospitals being constructed or under redevelopment and
this review may assist in informing practice on the preferred model of care. The review will also be looking
at the impact of team and total patient care from a global perspective on staff wellbeing to ensure best
available studies which meet the criteria are included in the review.

Inclusion criteria

Definitions

For the purposes of this review the following definitions will be used:

Nurse Turnover: Turnover includes voluntary and involuntary termination, as well as internal and
external transfers.19 Voluntary termination may include transferring from one department to another within
the same organization or when nursing staff voluntarily leave or transfer from their employment position.
Voluntary termination excludes dismissals, voluntary retirement, and leaves of absence as a result of
death, medical or maternity reasons.20 Involuntary termination is where employment is terminated by the
employer. Many studies do not distinguish between voluntary and involuntary turnover therefore for the
purpose of this study nurse turnover will be defined as the process in which nurses leave or transfer within
the hospital environment.

Absenteeism: Absenteeism (unplanned absence) will be defined as non-attendance at work where work
attendance is scheduled. This includes sick leave, and may include carers leave and bereavement leave.
This leave may be paid or unpaid.21 Work related injury leave will be excluded.

Nurse Stress: Defined as the “relationship between the person and the environment that is appraised by
the person as taxing or exceeding his or her resources and endangering his or her wellbeing.” 16 (p NP)

Nurse Burnout: Physical or mental collapse caused by overwork or stress.17

Skill Mix: The combination or grouping of different categories of workers that are employed for provision
of care to patients.22 Categories of workers for this review specifically refers to nursing staff employed for
provision of care.

Page 65
Types of participants

This review will consider studies that include all nurses working on general wards in the acute care
hospital sector. This includes registered general nurses or the International equivalent such as staff nurse
and professional nurse, enrolled nurses or the International equivalent such as licensed vocational nurse
or licensed practical nurse and unlicensed personnel such as nursing assistants or the International
equivalent such as nurse’s aide and auxiliary nurses.

This will review will exclude:

Nursing staff working on specialised wards and areas for example intensive/critical care areas, oncology
wards, paediatrics, midwifery, mental health, primary care and aged care sectors, as they utilize specific
models of care for their scope of practice.

Types of intervention(s)

This review will consider studies that investigate the use of a team nursing model when organizing nursing
work. The comparator will be utilization of a total patient care model.

Types of outcomes
The outcome of interest to this review will be staff wellbeing. Methodology for data collection will be
grouped from the primary research papers based on the types of outcomes measures or tools that were
used to promote homogeneity of pooled data. Data collection tools that have been used in initial
searches of papers have included questionnaires for the collection of responses for staff satisfaction. The
measurement tools considered for inclusion must be validated and reliable and need to have been
previously tested and found to be have acceptable techniques, examples of these tools are the Nursing
Work Index tool which measures nursing values in relation to job satisfaction and productivity, this tool has
been modified and used in various countries including Australia where it is referred to as the Nursing Work
Index – Revised: Australian Tool, (NWI-R:A tool).23 Another reliable tool is the McCloskey/Mueller
Satisfaction Scale (MMSS) which is a multidimensional questionnaire designed for hospital staff nurses.
There are 31 items; the response format is a five-point Likert scale. The Nurse Satisfaction Scale (NSS) is
also a validated tool which measures job satisfaction among nurses. The questionnaire is
multidimensional and has 24 items. The response format is a seven-point Likert scale.24

Maslach Burnout Inventory tool has been utilised to measure staff burnout and stress levels other tools
that measure staff burnout and stress will be considered for inclusion, providing it is a validated and tested
tool for measuring staff burnout and stress levels. Nursing turnover and absenteeism rates will be
extracted from included papers. Patient clinical outcomes will be excluded from the review.

Page 66
Types of studies

This review will consider quantitative studies that focus on but are not limited to staff turnover,
absenteeism, staff satisfaction, stress and burnout. Experimental and epidemiological study designs
including randomised controlled trials, non-randomised controlled trials, quasi-experimental, before and
after studies, prospective and retrospective cohort studies, case control studies and analytical cross
sectional studies for inclusion.

This review will also consider descriptive epidemiological study designs including case series, individual
case reports and descriptive cross sectional studies for inclusion.

Studies not published in English will be excluded from this review.

Search strategy

The search strategy aims to find both published and unpublished studies. A three-step search strategy will
be utilized in this review. An initial limited search of MEDLINE and CINAHL will be undertaken followed by
analysis of the text words contained in the title and abstract, and of the index terms used to describe the
article. A second search using all identified keywords and index terms will then be undertaken across all
included databases. Thirdly, the reference list of all identified reports and articles will be searched for
additional studies. Studies published in the English language will be considered for inclusion in the review.
Studies published from 1995 to September 2013 will be considered for inclusion in the review. In order to
analyse the most current and contemporary body of evidence, this review will only consider published
articles from 1995 onwards. To justify this time period it is critical to reflect upon the changes that have
occurred within Australia, in relation to a number of influences including nurse education, changes in
health acuity and workforce demands also saw the introduction of Assistants in Nursing (AIN’s) into the
acute care health workforce. Furthermore, since 1995, nursing practice was heavily influenced by
regulatory bodies such as the Australian Nursing and Midwifery Council.25, 26 These influences have
greatly affected and influenced models of care delivery. Studies prior to this period of time, considering
the significant movements and changes in workforce dynamics would be superfluous to the outcomes of
this systematic review.

The databases to be searched include:

 CINAHL

 PubMed

 Cochrane Library (CENTRAL)

 Scopus

 Embase
Page 67
  Science Direct

The search for unpublished studies will include:

 MedNar

 ProQuest Dissertations and Theses

Initial keywords: please refer to logic grid: (Appendix I).

Assessment of methodological quality

Quantitative papers selected for retrieval will be assessed by two independent reviewers for
methodological validity prior to inclusion in the review using standardised critical appraisal instruments
from the Joanna Briggs Institute Meta-Analysis of Statistics Assessment and Review Instrument
(JBI-MAStARI) (Appendix ll ). Any disagreements that arise between the reviewers will be resolved
through discussion, or with a third reviewer.

Data collection

Data will be extracted from papers included in the review using the standardised data extraction tool from
JBI-MAStARI (Appendix III). The data extracted will include specific details about the interventions,
populations, study methods and outcomes of significance to the review question and specific objectives.

Data synthesis

Quantitative data will, where possible be pooled in statistical meta-analysis using JBI-MAStARI. All results
will be subject to double data entry. Effect sizes expressed as odds ratio (for categorical data) and
weighted mean differences (for continuous data) and their 95% confidence intervals will be calculated for
analysis. Heterogeneity will be assessed statistically using the standard Chi-square and also explored
using subgroup analyses based on the different study designs included in this review. Where statistical
pooling is not possible the findings will be presented in narrative form including tables and figures to aid in
data presentation where appropriate.

Conflicts of interest

No conflicts of interest to declare

Acknowledgements

As this systematic review forms partial submission for the degree award of Masters of Clinical Science, a
secondary reviewer (Scott King, MSc candidate) will be utilized for critical appraisal.

I would like to thank my supervisors, Associate Professor Lesley Long AM and Dr Karolina Lisy at the
Page 68
Joanna Briggs Institute Adelaide for their guidance and support with this review.

References

1. Fowler, J, Hardy, J & Howarth. Trialing collaborative nursing models of care: the impact of
change. Australian Journal of Advanced Nursing.2006: 23(4):40-6.

2. Pearson A, Fitzgerald M, Walsh K, Long L, Borbasi S & Heinrich N. Patterns of nursing care.
University of Adelaide. Department of Clinical N, editors. Adelaide: Dept. of Clinical Nursing, University of
Adelaide; 1999, Research Monograph Series No. 5.

3. Fairbrother G, Jones A, Rivas K. Changing model of nursing care from individual patient
allocation to team nursing in the acute inpatient environment. Contemporary Nurse: A Journal for the
Australian Nursing Profession. 2010;35(2):202-20.

4. Tiedeman ME, Lookinland S. Traditional models of care delivery: what have we learned? The
Journal of nursing administration. 2004 Jun;34(6):291-7.

5. Tran DT, Johnson M, Fernandez R, Jones S. A shared care model vs. a patient allocation model
of nursing care delivery: comparing nursing staff satisfaction and stress outcomes. International Journal of
Nursing Practice. 2010;16(2):148-58.

6. Ferguson L, Cloffi J. Team nursing: experience of nurse managers in acute care settings.
Australian Journal of Advanced Nursing. ND:28 (4):5-11

7. New South Wales Department of Health. First report on the models of care project February-April
2005. New South Wales Department of Health, Health February 2006.;[cited 6/7/2013] Available from:
http://www0.health.nsw.gov.au/pubs/2006/pdf/models_of_care.pdf

8. Australia’s Health Workforce Series – Nurses in focus Adelaide: Health Workforce Australia.
2013;[cited 14/07/2013] Available from:

https://www.hwa.gov.au/sites/uploads/Nurses-in-Focus-FINAL.pdf

9. Aiken LH, Clarke SP, Sloane DM, Sochalski JA. An International Perspective on Hospital Nurses’
Work Environments: The Case for Reform. Policy, Politics, & Nursing Practice. 2001 November 1,
2001;2(4):255-63.

10. Needleman J, Buerhaus P. Nurse staffing and patient safety: current knowledge and implications
for action. International Journal for Quality in Health Care. 2003 August 1, 2003;15(4):275-7.

11. Lang TA, Hodge M, Olson V, Romano PS, Kravitz RL. Nurse-patient ratios: a systematic review
on the effects of nurse staffing on patient, nurse employee, and hospital outcomes. The Journal of nursing
administration. 2004 Jul-Aug;34(7-8):326-37.

12. Butler M, Collins R, Drennan J, Halligan P, O’Matuna DP, Schultz TJ, Sheridan A & Villis E.
Hospital nurse staffing models and patient and staff-related outcomes (Review). Cochrane Database of
Systematic Reviews, John Wiley & Sons, Ltd. 2011

Page 69
13. Fernandez R, Johnson M, Tran DT, Miranda C. Models of care in nursing: a systematic review.
International Journal of Evidence-Based Healthcare. 2012;10(4):324-37.

14. Adams A, Bond S. Staffing in acute hospital wards: part 1. The relationship between number of
nurses and ward organizational environment. Journal of Nursing Management. 2003;11(5):287.

15. Eagar SC, Cowin LS, Gregory L, Firtko A. Scope of practice conflict in nursing: A new war or just
the same battle? Contemporary Nurse: A Journal for the Australian Nursing Profession.
2010;36(1/2):86-95.

16. Jennings BM. Work Stress and Burnout Among Nurses: Role of the Work Environment and
Working Conditions. In: Hughes RG, editor. Patient Safety and Quality: An Evidence-Based Handbook for
Nurses. Rockville (MD): Agency for Healthcare Research and Quality (US); 2008 Apr. Chapter 26.[cited
14/7/2013] Available from: http://www.ncbi.nlm.nih.gov/books/NBK2668/

17. Oxford Press, Oxford Dictionary Online, Oxford Press; [cited 14/7/2013] Available from:
http://oxforddictionaries.com/definition/english/burnout

18. Australian Nursing and Midwifery Council. Delegation and Supervision of Nurses; [cited
14/7/2013] Available from: http://www.anmac.org.au/

19. Hayes LJ, Pallas-O’Brien L, Duffield C, Shamian J, Buchan J, Hughes F Spence Laschinger HK,
North N, Stone PW. Nurse turnover: a literature review. International Journal of Nursing Studies.
2006;43:237-263

20. Pallas-O’Brien L, Griffin P, Shamian J, Buchan J, Duffield C, Hughes F, Spence Laschinger HK,
North N, Stone PW. The impact of nurse turnover on patient, nurse, and system outcomes: a pilot study
and focus for a multicenter International study. Policy, Politics & Nursing Practice. 2006;7:169-179

21. The Australasian Faculty of Occupational Medicine. Workplace attendance and absenteeism
Royal Australian College of Physicians. December 1999. [cited 12/8/2013] Available from:
http://www.racp.edu.au/download.cfm?downloadfile=5DE5DDB4-E65C-FB6E-149B89D88BC
9AD9B&typename=dmFile&fieldname=filename

22. McGillis Hall L. Staff mix models: complementary or substitution roles for nurses. Nursing
Administration Quarterly. 1997;21(2):31-39

23. Joyce JT, Crookes PA. Developing a tool to measure magnetism in Australian nursing
environments. Australian Journal of Advanced Nursing (online). 2007;25(1):17-23;[cited
12/08/2013].Available from http://search.proquest.com/docview/204201477?accountid=148228

24. Van Saane N, Sluiter JK, Verbeek JH AM, Frings-Dresen MHW. Reliability and validity of
instruments measuring job satisfaction a systematic review. Occupational Medicine. 2003;53 (3):191-200

25. Australian Nursing Midwifery Council. National Competency Standards for the Enrolled Nurse.
Australian Nursing Midwifery Council. 2002 [cited 24/10/2013] Available from:
http://www.nursingmidwiferyboard.gov.au/Codes-Guidelines-Statements/Codes-Guidelines.aspx#compe
tencystandards

26. Australian Nursing Midwifery Council. National Competency Standards for the Registered
Nurse. Australian Nursing Midwifery Council. 2006 [cited 24/10/2013] Available from:

Page 70
http://www.nursingmidwiferyboard.gov.au/Codes-Guidelines-Statements/Codes-Guidelines.aspx#compe
tencystandards

Page 71
Appendix II: Search strategy

PubMed Database Search Strategy

(Total patient care [TW] OR patient allocation [TW] OR Team nursing [TW] OR nursing, team [MH] OR
nursing, team [TW] OR models, nursing [MH] OR models, nursing [TW] OR nursing model* [TW] OR
personnel staffing and scheduling [MH] OR personnel staffing and scheduling [TW]) OR nursing care
delivery system* [TW] OR patient care delivery system* [TW] OR primary nursing [TW] OR modular
nursing [TW] OR functional nursing [TW] OR collegiality [TW]) AND (absenteeism[MH] OR absenteeism
[TW] OR wellbeing [TW] OR well being [TW] OR well-being [TW] OR job satisfaction[MH] OR job
satisfaction [TW] OR personnel turnover [MH] OR personnel turnover [TW] OR turnover [TI&AB] OR
stress, psychological [MH] OR stress, psychological [TW] OR stress [TW] OR burnout [TW] OR mental
fatigue [MH] OR mental fatigue [TW] OR fatigue [TW] OR burnout, Professional/Nursing [MH] OR sick
leave [MH] OR sick leave [TW]) AND (nursing staff [MH] OR nursing staff [TW] OR Nursing Staff, Hospital
[MH]OR Hospital Units [MH] OR general ward [TW] OR ward units [TW] OR nurses [MH] OR nurses [TW])

Search date: 21/4/2014, articles in English language only.

CINHAL Database Search Strategy

(Nursing Care Delivery Systems+ OR Total Patient Care Nursing OR nursing care delivery systems OR
total patient care nursing OR total patient care OR team nursing OR team nursing OR nursing team* OR
nursing model* of care OR Personnel Staffing and Scheduling+ OR personnel staffing and scheduling OR
patient care delivery system*primary nursing OR "modular nursing OR functional nursing OR
Collegiality)AND (MH Job Satisfaction OR job satisfaction OR MH Personnel Turnover OR personnel
turnover OR MH Stress, Psychological+ OR stress, psychological OR MH Stress, Occupational+ OR
stress, occupational OR MH Burnout, Professional OR burnout OR Burnout, Professional OR MH
Fatigue+/NU OR mental fatigue OR employee stress OR MH Sick Leave OR Sick Leave OR MH Family
and Medical Leave OR MH Quality of Working Life OR quality of working life OR MH Personnel Turnover
OR personnel turnover OR MH Personnel Retention OR personnel retention OR MH Psychological
Well-Being OR well being OR Psychological Well-Being OR MH Absenteeism OR absenteeism OR MH
Nursing Manpower)AND(MH Nursing Staff, Hospital OR MH Nurses OR nurses OR MH Hospital Units
OR hospital units OR general ward)

Search date: 21/4/2014, articles in English language only.

COCHRANE Database Search Strategy

(Total patient care OR patient allocation OR team nursing OR [Nursing, Team] OR [Models, Nursing] OR
[Personnel Staffing and Scheduling] OR primary nursing OR functional nursing OR modular nursing) AND
Page 72
([Absenteeism] OR absenteeism OR [Job Satisfaction] OR wellbeing OR [Personnel Turnover] OR
[Stress, Psychological] OR [Burnout, Professional] OR burnout OR sick leave OR [Mental Fatigue] OR job
satisfaction) AND ([Nursing Staff] OR [Nursing Staff, Hospital] OR [Patients' Rooms] OR general wards
OR" hospital units OR nurse)

Search date: 23/4/2014, articles in English language only

SCOPUS Database Search Strategy

(Collegiality OR nursing care delivery system OR total patient care OR team nursing OR nursing team OR
nursing model of care OR personnel staffing and scheduling OR patient care delivery system OR primary
nursing OR modular nursing OR functional nursing) AND (personnel retention OR turnover OR staff
turnover OR absenteeism OR wellbeing OR job satisfaction OR occupational stress OR burnout OR
mental fatigue OR sick leave OR stress) AND (nursing staff OR nurses OR hospital nurses OR wards OR
hospital units)

Search date: 21/4/2014, articles in English language only

EMBASE Database Search Strategy

(Nursing care delivery system OR total patient care OR patient allocation OR team nursing OR nursing
team OR nursing model of care OR nursing models of care OR patient care delivery system OR patient
care delivery systems OR nursing care delivery systems OR modular nursing OR primary nursing OR
functional nursing OR personnel management OR Collegiality OR team hierarchy) AND (absenteeism
OR job satisfaction OR job satisfaction/exp OR personnel turnover OR quality of working life OR job
stress/exp OR job stress OR mental fatigue OR burnout professional OR burnout/exp OR sick leave OR
medical leave OR personnel retention OR well$being) AND (nursing staff OR hospital units OR nurse
OR ward OR nurses/exp)

Search date: 21/4/2014, articles in English language only

Science Direct Database Search Strategy

(Team nursing OR nursing team* OR personnel staffing and scheduling OR nursing care delivery system*
OR patient care delivery system* OR primary nursing OR modular nursing OR functional nursing OR
nursing model* OR model* of nursing OR total patient care OR patient allocation) AND (mental fatigue OR
fatigue OR sick leave OR {sick-leave} OR quality of working life OR burnout OR {burn-out} OR
professional burnout OR absenteeism OR wellbeing OR {well-being} OR well being OR job satisfaction
OR personnel turnover OR turnover OR stress OR psychological stress) AND (general ward OR acute
care OR hospital unit OR hospital ward)

Page 73
Search date: 25/4/2014, articles in English language only

ProQuest Dissertations & Theses Database Search Strategy

(Total patient care OR patient allocation OR team nursing OR nursing team OR nursing model* OR
model* of nursing OR Models AND Nursing OR personnel staffing and scheduling OR patient care
delivery system* OR nursing care delivery system* OR primary nursing OR modular nursing OR
functional nursing AND personnel turnover OR turnover OR SU.exact TURNOVER AND SU.exact
NURSING OR SU.exact HEALTH SCIENCES NURSING OR absenteeism OR SU.exact
ABSENTEEISM OR wellbeing OR well being OR quality of working life OR job satisfaction OR SU.exact
JOB SATISFACTION AND SU.exact WORK ENVIRONMENT OR PER.exact WORK ENVIRONMENT
OR stress OR SU.exact STRESS OR ORG.exact STRESS AND SU.exact NURSING OR SU.exact
HEALTH SCIENCES NURSING OR burnout OR SU.exact BURNOUT OR professional burnout OR
mental fatigue OR fatigue OR sick leave) AND (hospital nurse* OR SU.exact HOSPITALS OR SU.exact
HOSPITAL AND SU.exact NURSES OR general ward* OR hospital unit* OR hospital ward*)

Search date: 26/4/2014, articles in English language only

Page 74
Appendix III: Appraisal instrument

MAStARI appraisal instrument

Page 75
Appendix IV: Data Extraction Instruments

MAStARI data extraction instrument

Page 76
Page 77
 Appendix V: Characteristics of included studies

Study, setting Participants Study design and method Intervention Comparator Outcomes and Findings
and sample size measures relevant
to review

Fairbrother et al. Gender Non randomized, Team nursing Total patient Nursing Workplace Higher extrinsic job satisfaction in
(2010)18 Not addressed quasi-experimental care Satisfaction team nursing wards.
Questionnaire
New South Wales, Age Self- (NWSQ) An improvement in job satisfaction
Australia Not addressed completion surveys for graduate nurses in team nursing
wards.
12 med/surg Designation
wards EN Enrolled Nurses had a higher job
New graduate RN’s satisfaction at baseline and 12
(n=221) RN’s month follow-up period, although
Clinical nurse specialists there was a small decrease in job
satisfaction at 12 months for this
group
Bed capacity Overall, job satisfaction equivalent
Team nursing wards -16-26 beds between team nursing and
individual patient allocation wards.
Total patient care wards - 16-26 beds
Reduced vacancy rates in team
nursing and individual patient
allocation wards.

Staff turnover Team nursing wards improved

Number of full time vacancy rates quicker than
equivalent (FTE) individual patient allocation wards,
vacancies divided by however not a statistically significant
number of FTE’s improvement
allocated

Page 78
Tran et al. Team Total Quasi- Team nursing Total patient Job satisfaction- Decrease in satisfaction with
(2010)20 nursing patient care Experimental with a care Job Descriptive Index co-worker in team nursing wards.
(n=74) (n=51) comparison group (JDI) and
New South Wales, Gender (before and after design) Job in General (JIG) Overall minimal difference in models
Australia scale with job satisfaction. A patient
Female 64 46 Self- allocation model has advantages in
completion surveys wards with predominantly RNs.
Male 10 3
4 Medical and 4
Surgical Wards Age If a mix of skill and experience then
team nursing of benefit.
(n=125) <30 22 5

30-39 12 10 Nurses less satisfied if working with

increasing levels of stress,
40-49 17 16
Stress at work prolonged tension and uncertainty in
>50 21 15 role.
Stress in General
Designation (SIG) Nurses demonstrated a neutral level
of threatening characteristics in their
EN 21 7 Job tension- Tension job and
Index by Lyons A moderate level of pressure.
RN 52 41

Bed Capacity
Not addressed
Wells et al. (2011) Gender This study was described as a Total patient Team Job satisfaction- Low response rates.
Not addressed mixed method, longitudinal, care nursing Index of Work
Newfoundland descriptive design. Satisfaction (IWS) Nurses mostly satisfied with
and Labrador Age Based on methods described professional status, interaction and
Canada Not addressed it was considered by autonomy, least satisfied with tasks,
reviewers to be an policy and pay.
2 Acute Care units Designation uncontrolled before and after
RN-Registered Nurses experimental study. In this Pay most important job variable.
(n=78) LPN- Licensed practical nurses study two acute care nursing
units which previously Transition to total patient care did
practiced a team nursing not have a significant effect on job
Bed Capacity model changed to a total satisfaction.
52 beds patient care model to assess
how the change affected
Page 79
nurse’s job satisfaction.

Self-
completion surveys

Page 80
Appendix VI: List of excluded studies

1. Adams A, Bond S. Clinical specialty and organizational features of acute hospital wards. J Adv
Nurs. 1997 Dec; 26(6):1158-67.
Reason for exclusion: Study does not meet inclusion criteria, discussed clinical specialty.
2. Adams A, Bond S. Hospital nurses' job satisfaction, individual and organizational characteristics. J
Adv Nursing. 2000; 32(3):536-43.
Reason for exclusion: Study does not meet inclusion criteria, discussed ward environment.
3. Adams A, Bond S. Staffing in acute hospital wards: part 1. The relationship between number of
nurses and ward organizational environment. J Nurs Manage. 2003; 11(5):287-92.
Reason for exclusion: Study does not meet inclusion criteria, no useable data, compared
devolved, two-tier and centralized organization.
4. Adams A, Bond S. Staffing in acute hospital wards: part 2. Relationships between grade mix, staff
stability and features of ward organizational environment. J Nurs Manage. 2003; 11(5):293-8.
Reason for exclusion: Study does not meet inclusion criteria, compared devolved, two-tier and
centralized organization models.
5. Adams A, Bond S, Arber S. Development and validation of scales to measure organisational
features of acute hospital wards. Int J Nurs Stud. 1995; 32(6):612-27.
Reason for exclusion: Study does not meet inclusion criteria, discussed development of scale.
6. Adams A, Bond S, Hale CA. Nursing organizational practice and its relationship with other features
of ward organization and job satisfaction. J Adv Nursing. 1998; 27(6):1212-22.
Reason for exclusion: Study does not meet inclusion criteria, compared devolved, two-tier and
centralized organization models.
7. Aiken LH, Clarke SP, Sloane DM, Sochalski JA. An international perspective on hospital nurses'
work environments: the case for reform. Policy Polit Nurs Pract. 2001; 2(4):255-63.
Reason for exclusion: Study does not meet inclusion criteria, models not compared.
8. Bacon CT, Mark B. Organizational effects on patient satisfaction in hospital medical-surgical units.
J Nurs Adm. 2009; 39(5):220-7.
Reason for exclusion: Study does not meet inclusion criteria, models not compared.
9. Barkell N, Killinger K, Schultz S. The relationship between nurse staffing models and patient
outcomes: a descriptive study. Outcomes management. 2001; 6(1):27-33.
Reason for exclusion: Study does not meet inclusion criteria, reviewed models of care in
terms of patient outcomes.
10. Boumans NP, Landeweerd JA. Nurses' well-being in a primary nursing care setting in The
Netherlands. Scand J Caring Sci. 1999; 13(2):116-22.
Reason for exclusion: Study does not meet inclusion criteria, compared different models of
care.

Page 81
11. Choi SPP, Cheung K, Pang SMC. Attributes of nursing work environment as predictors of registered
nurses' job satisfaction and intention to leave. J Nurs Manage. 2013; 21(3):429-39.
Reason for exclusion: Study does not meet inclusion criteria, models not compared.
12. Cioffi J, Ferguson Am L. Team nursing in acute care settings: nurses' experiences. Contemporary
Nurse: A Journal for the Australian Nursing Profession. 2009; 33(1):2-12.
Reason for exclusion: Study does not meet inclusion criteria, qualitative study.
13. Duffield C, Diers D, O'Brien-Pallas L, Aisbett C, Roche M, King M, et al. Nursing staffing, nursing
workload, the work environment and patient outcomes. Appl Nurs Res. 2011; 24(4):244-55.
Reason for exclusion: Study does not meet inclusion criteria, reviewed skill mix and patient
outcomes.
14. Estryn-Behar M, Van Der Heijden BIJM, Oginska H, Camerino D, Le Nezet O, Conway PM, et al.
The impact of social work environment, teamwork characteristics, burnout, and personal factors upon
intent to leave among European nurses. Med Care. 2007; 45(10):939-50.
Reason for exclusion: Study does not meet inclusion criteria, models not compared.
15. Fernandez R, Tran DT, Johnson M, Jones S. Interdisciplinary communication in general medical
and surgical wards using two different models of nursing care delivery. J Nurs Manage. 2010;
18(3):265-74.
Reason for exclusion: Study does not meet inclusion criteria, reviewed team nursing and total
patient care in terms of communication with the interdisciplinary team.
16. Fowler J, Hardy J, Howarth T. Trialing collaborative nursing models of care: the impact of change.
Aust J Adv Nurs. 2006; 23(4):40-6.
Reason for exclusion: Study does not meet inclusion criteria, unable to identify
pre-implementation model of care.
17. Hall C, McCutcheon H, Deuter K, Matricciani L. Evaluating and improving a model of nursing care
delivery: a process of partnership. Collegian. 2012; 19(4):203-10.
Reason for exclusion: Study does not meet inclusion criteria, qualitative study.
18. Hayman B, Cioffi J, Wilkes L. Redesign of the model of nursing practice in an acute care ward:
nurses' experiences. Collegian. 2006; 13(1):31-6.
Reason for exclusion: Study does not meet inclusion criteria, qualitative study.
19. Heinen MM, van Achterberg T, Schwendimann R, Zander B, Matthews A, Kózka M, et al. Nurses'
intention to leave their profession: A cross sectional observational study in 10 European countries. Int. J
Nurs Stud. 2013; 50(2):174-84.
Reason for exclusion: Study does not meet inclusion criteria, models not compared.
20. Kalisch BJ, Begeny SM. Improving nursing unit teamwork. J Nurs Adm. 2005; 35(12):550-6.
Reason for exclusion: Study does not meet inclusion criteria, qualitative study.
21. Kalisch BJ, Lee H. Nursing teamwork, staff characteristics, work schedules, and staffing. Health
Care Manage Rev. 2009; 34(4):323-33.
Reason for exclusion: Study does not meet inclusion criteria, discussed nursing teamwork.

Page 82
22. Kanai-Pak M, Aiken LH, Sloane DM, Poghosyan L. Poor work environments and nurse inexperience
are associated with burnout, job dissatisfaction and quality deficits in Japanese hospitals. J Clin
Nursing. 2008; 17(24):3324-9.
Reason for exclusion: Study does not meet inclusion criteria, models not compared.
23. Kangas S, Kee CC, McKee-Waddle R. Organizational factors, nurses' job satisfaction, and patient
satisfaction with nursing care. J Nurs Adm. 1999; 29(1):32-42.
Reason for exclusion: Study does not meet inclusion criteria, compared different models of
care.
24. Kivimaki M, Makinen A, Elovainio M, Vahtera J, Virtanen M, Firth-Cozens J. Sickness absence and
the organization of nursing care among hospital nurses. Scand J Work Environ Health. 2004 Dec;
30(6):468-76.
Reason for exclusion: Study does not meet inclusion criteria, compared different models of
care.
25. Kivimaki M, Voutilainen P, Koskinen P. Job enrichment, work motivation, and job satisfaction in
hospital wards: testing the job characteristics model. J Nurs Manage. 1995; 3(2):87-91.
Reason for exclusion: Study does not meet inclusion criteria, compared different models of
care.
26. Leveck ML, Jones CB. The nursing practice environment, staff retention, and quality of care. Res
Nurs Health. 1996 Aug; 19(4):331-43.
Reason for exclusion: Study does not meet inclusion criteria, included all hospital units.
27. Mäkinen A, Kivimäki M, Elovainio M, Virtanen M. Organization of nursing care and stressful work
characteristics. J Adv Nursing. 2003; 43(2):197-205.
Reason for exclusion: Study does not meet inclusion criteria, compared different models of
care.
28. Mäkinen A, Kivimäki M, Elovainio M, Virtanen M, Bond S. Organization of nursing care as a
determinant of job satisfaction among hospital nurses. J Nurs Manage. 2003; 11(5):299-306.
Reason for exclusion: Study does not meet inclusion criteria, compared different models of
care.
29. Mcgillis Hall LM. Nursing staff mix models and outcomes. J Adv Nursing. 2003; 44(2):217-26.
Reason for exclusion: Study does not meet inclusion criteria, referred to skill mix models.
30. McGillis Hall L, Doran D. Nurses' perceptions of hospital work environments. J Nurs Manage. 2007;
15(3):264-73.
Reason for exclusion: Study does not meet inclusion criteria, compared different models of
care.
31. Mcgillis Hall L, Doran D, Baker GR, Pink GH, Sidani S, O'Brien-Pallas L, et al. Nurse staffing models
as predictors of patient outcomes. Med Care. 2003; 41(9):1096-109.
Reason for exclusion: Study does not meet inclusion criteria, reviewed models of care in
terms of patient outcomes.

Page 83
32. McGillis Hall L, Doran D, Pink GH. Nurse staffing models, nursing hours, and patient safety
outcomes. J Nurs Adm. 2004; 34(1):41-5.
Reason for exclusion: Study does not meet inclusion criteria, reviewed models of care in
terms of patient outcomes and costs.
33. Needleman J, Buerhaus P, Mattke S, Stewart M, Zelevinsky K. Nurse-staffing levels and the quality
of care in hospitals. New Engl J Med. 2002; 346(22):1715-22.
Reason for exclusion: Study does not meet inclusion criteria, reviewed staff mix model and
focused on patient outcomes and cost of nursing hour per patient day.
34. O'Connell B, Duke M, Bennett P, Crawford S, Korfiatis V. The trials and tribulations of team-nursing.
Collegian. 2006; 13(3):11-7.
Reason for exclusion: Study does not meet inclusion criteria, qualitative study.
35. Pierce LL, Hazel CM, Mion LC. Effect of a professional practice model on autonomy, job satisfaction
and turnover. Nurs Manage. 1996; 27(2):48M, 48P, 48R-T.
Reason for exclusion: Study does not meet inclusion criteria, models not compared.
36. Sjetne IS, Veenstra M, Ellefsen B, Stavem K. Service quality in hospital wards with different nursing
organization: nurses' ratings. J Adv Nursing. 2009; 65(2):325-36.
Reason for exclusion: Study does not meet inclusion criteria, compared different models of
care.
37. Tourangeau AE, White P, Scott J, McAllister M, Giles L. Evaluation of a partnership model of care
delivery involving registered nurses and unlicensed assistive personnel. Can J Nurs Leadersh. 1999;
12(2):4-20.
Reason for exclusion: Study does not meet inclusion criteria, compared different models of
care.
38. Tummers GER, Landeweerd JA, van Merode GG. Organization, work and work reactions: a study of
the relationship between organizational aspects of nursing and nurses' work characteristics and work
reactions. Scand J Caring Sci. 2002; 16(1):52-8.
Reason for exclusion: Study does not meet inclusion criteria, compared different models of
care.
39. Van Bogaert P, Meulemans H, Clarke S, Vermeyen K, Van De Heyning P. Hospital nurse practice
environment, burnout, job outcomes and quality of care: Test of a structural equation model. J Adv
Nursing. 2009; 65(10):2175-85.
Reason for exclusion: Study does not meet inclusion criteria, models not compared.
40. Vlerick P. Burnout and work organization in hospital wards: a cross-validation study. Work Stress.
1996; 10(3):257-65.
Reason for exclusion: Study does not meet inclusion criteria, compared different models of
care.

Page 84
Appendix VII: Studies included in review

Fairbrother G, Jones A, Rivas K. Changing model of nursing care from individual patient allocation to
team nursing in the acute inpatient environment. Contemp Nurse. 2010; 35(2):202-20.

Tran DT, Johnson M, Fernandez R, Jones S. A shared care model vs. a patient allocation model of
nursing care delivery: comparing nursing staff satisfaction and stress outcomes. Int J Nurs Pract. 2010;
16(2):148-58.

Wells J, Manuel M, Cunning G. Changing the model of care delivery: nurses' perceptions of job
satisfaction and care effectiveness. J Nurs Manage. 2011; 19(6):777-85.

Page 85
Appendix VIII: Editorial

JBI Database of Systematic Reviews & Implementation Reports 2015; 13(11):1-3

EDITORIAL

Can nurses’ wellbeing be linked to model of care or other influences?

Nurses make up the largest profession in the health workforce1 and therefore account for a large
component of a hospital’s workforce expenditure. The nursing workforce is influenced by many factors
which include rapid technological and treatment changes, workforce demographics, budgetary
constraints, and recruitment and retention of nursing staff. A productive workforce requires a positive
organizational culture at the center of which is the wellbeing of employees. Workforce modeling predicts
that if significant reforms are not made in Australia to address issues in training, education and
managing demand through increased efficiencies, there will be a shortage of nurses of up to 27%, or
approximately 109,000 nurses, by 20252 similar forecasts have been made internationally. In the
hospital setting, restructuring or redesigning of nursing work by either reducing the registered nurse skill
mix or the number of qualified nurses is a method used to reduce costs. The impact of these strategies
on the quality of care nurses provide and on nurses’ wellbeing is unclear, however the intention is that
patient care is not compromised as a result. Governments, organizations and nursing leaders need to
ensure that the current and future nursing workforce is equipped and able to adapt to meet these needs
and to meet the community’s expectation to receive safe, empathetic and effective care. Organizations
need to ensure that staff have the appropriate skills and knowledge base to deliver quality nursing care
in a fiscally responsible manner.

The current issues facing the nursing workforce outlined above will continue. Changes in models of care
such as creation of advanced practice roles, increasing scope of practice and hospital restructuring are
ways in which these issues have been and continue to be addressed.3 The term model of care is used
extensively and can broadly be defined as the way in which healthcare services are delivered. 4 In acute
hospital wards, nursing work is organized, allocated and delivered using a number of established
nursing models of care; these include but are not limited to team nursing, total patient care, task method
and primary nursing.5,6 These four nursing models of care are the dominant, traditional models which
are internationally recognized and described in the literature, although in recent years other models of
care, hybrids or combinations of models have emerged.7

The model of nursing care chosen is usually dependent on nursing resources and patient care needs.
When reviewing staffing requirements, patient acuity needs to be considered. For example, increased
Page 86
registered nurse hours per patient day have been linked to decreased rates of pneumonia, sepsis and
shock8 and can be attributed to better care outcomes for patients.9 The number of patients that nurses
are caring for is also a significant factor and an increase in the number of patients per nurse can cause
failure to rescue, increase in patient mortality, decline in patient safety and decrease in quality of care. 10
These clinical implications and the effect different models of care have on patient outcomes have been
addressed in the literature.11 However, the impact of the model of care on outcomes related to nurses’
wellbeing has received considerably less attention.

The review published in the current issue of the JBI Database of Systematic Reviews and
Implementation Reports by King et al.12 aimed to assess the impact of the two dominant models of care
used in Australia, team nursing and total patient care, on outcomes related to nurses’ wellbeing.
Results of the review demonstrated that there was no statistically significant difference in the overall job
satisfaction, stress, job tension or staff turnover using a team nursing or a total patient care model. The
review did however demonstrate greater satisfaction with the work environment under a team nursing
model, and importantly found that graduate nurses were more satisfied within a team nursing compared
with a total patient care model. A team nursing model can support novice, inexperienced nursing staff,
and may be the most appropriate model when there is a lower registered nurse skill mix, however there
must be clarity on the roles and responsibilities of each team member to ensure satisfaction with
co-workers. A significant difficulty encountered during the conduct of this review was inconsistency in
the terminology and language used to name and describe the models of care in the literature,
highlighting the need for consensus on terminology.

Findings from the review may assist policy makers, nursing leaders and hospital executives in
determining an evidence-based decision on which model of care to implement to achieve the best
outcomes for nurses’ wellbeing. However, the review indicated that issues such as leadership, skill mix,
retention of staff and clearly defined nursing roles may have a greater influence on nurses’ wellbeing
than model of care. Nursing leaders and organizations need to foster and develop healthy productive
workplaces to achieve optimum patient outcomes in a cost effective environment. Nursing knowledge,
experience, skill level, workload and patient acuity should be the priority in determining the model of
care.
Allana King
RGN, BNurs, MHlthAdmin, CFJBI, Royal Adelaide Hospital
Associate Professor Lesley Long
AM PhD, MHA, Ba Nsg, RGN, University of Adelaide
Dr Karolina Lisy
Research Fellow, Implementation Science, The Joanna Briggs Institute

Page 87
References

1. Wong F, Liu H, Wang H, Anderson D, Seib C, Molasiotis A. Global Nursing Issues and
Developments: Analysis of World Health Organization Documents. J Nurs Scholarsh. 2015;
47(6):574-83.

2. Australia HW. Health Workforce 2025 Doctors, Nurses and Midwives. Adelaide, Australia. 2012; p.
1-197.

3. Aiken LH, Clarke SP, Sloane DM, Sochalski JA. An international perspective on hospital nurses' work
environments: the case for reform. Policy Polit Nurs Pract. 2001; 2(4):255-63.

4. Agency for Clinical Innovation. Understanding the process to develop a model of care. New South
Wales, Australia. 2013. p. 1-20.

5. Pearson A, FitzGerald M, Walsh K, Long L, Borbasi S, Heinrich N. Patterns of Nursing Care.

University of Adelaide, Department of Clinical Nursing; 1999. p. 1-128.

6. Tiedeman ME, Lookinland S. Traditional models of care delivery: what have we learned? J Nurs Adm.
2004; 34(6):291-7.

7. O'Connell B, Duke M, Bennett P, Crawford S, Korfiatis V. The trials and tribulations of team-nursing.
Collegian. 2006; 13(3):11-7.

8. Duffield C, Diers D, O'Brien-Pallas L, Aisbett C, Roche M, King M, et al. Nursing staffing, nursing
workload, the work environment and patient outcomes. Appl Nurs Res. 2011; 24(4):244-55.

9. Needleman J, Buerhaus P, Mattke S, Stewart M, Zelevinsky K. Nurse-staffing levels and the quality of
care in hospitals. New Engl J Med. 2002; 346(22):1715-22.

10. Pearson A, Pallas LO, Thomson D, Doucette E, Tucker D, Wiechula R, et al. Systematic review of
evidence on the impact of nursing workload and staffing on establishing healthy work environments. Int
J Evid Based Healthc . 2006; 4(4):337-84.

11. McGillis Hall L, Doran D, Pink GH. Nurse staffing models, nursing hours, and patient safety
outcomes. J Nurs Adm. 2004; 34(1):41-5.

12. King A, Long L, Lisy K. Effectiveness of team nursing compared with total patient care on staff
wellbeing when organizing nursing work in acute care wards: a systematic review. JBI Database System
Rev Implement Rep. 2015; 13(11):128-168

Page 88
Appendix IX: JBI Grades of Recommendation

JBI Grades of Recommendation

A ‘strong’ recommendation for a certain health management strategy where:

1. it is clear that desirable effects outweigh undesirable effects of the strategy;

Grade A
2. where there is evidence of adequate quality supporting its use;
3. there is a benefit or no impact on resource use, and
4. Values, preferences and the patient experience have been taken into account.
A ‘weak’ recommendation for a certain health management strategy where:

1. desirable effects appear to outweigh undesirable effects of the strategy, although this is
not as clear;
Grade B 2. where there is evidence supporting its use, although this may not be of high quality;
3. there is a benefit, no impact or minimal impact on resource use, and
4. Values, preferences and the patient experience may or may not have been taken into
account.

Page 89