Research in Gerontological Nursing

Instrument Development 

Identifying and Validating the Components of Nursing Practice Models for Long-Term Care Facilities

Christine Mueller, PhD, RN, FAAN; Kay Savik, MS

Abstract

Nursing practice models (NPMs) provide the framework for the design and delivery of nursing care to residents in long-term care (LTC) facilities and characterize the manner in which nursing staff assemble to accomplish clinical goals. The purpose of this study was to identify and validate the distinctive components of NPMs in LTC facilities and develop an instrument to describe and evaluate NPMs in such settings. The study included validation of the NPM components through a literature review and focus groups with nursing staff from LTC facilities; development and modification of the Nursing Practice Model Questionnaire (NPMQ); and examination of the validity and reliability of the NPMQ through pilot testing in 15 LTC facilities with 508 nursing staff. Five factors—decision making, informal continuity of information, formal continuity of information, continuity of care, and accountability—comprise the five subscales of the NPMQ, a 37-item questionnaire with established respectable validity and reliability.

Abstract

Nursing practice models (NPMs) provide the framework for the design and delivery of nursing care to residents in long-term care (LTC) facilities and characterize the manner in which nursing staff assemble to accomplish clinical goals. The purpose of this study was to identify and validate the distinctive components of NPMs in LTC facilities and develop an instrument to describe and evaluate NPMs in such settings. The study included validation of the NPM components through a literature review and focus groups with nursing staff from LTC facilities; development and modification of the Nursing Practice Model Questionnaire (NPMQ); and examination of the validity and reliability of the NPMQ through pilot testing in 15 LTC facilities with 508 nursing staff. Five factors—decision making, informal continuity of information, formal continuity of information, continuity of care, and accountability—comprise the five subscales of the NPMQ, a 37-item questionnaire with established respectable validity and reliability.

The physical and psychosocial well-being of residents in long-term care (LTC) facilities (also referred to in this article as nursing homes and nursing facilities) is directly dependent on the care provided by nursing staff. Yet, the most serious issue in LTC facilities is having enough qualified nursing staff to provide that care (Collier & Harrington, 2008). The national nursing home workforce crisis is related to a variety of complex factors, including a growing older adult population (U.S. Administration on Aging, 2008), the dramatic rise in the number of patients with complex clinical needs and extensive rehabilitation admitted to nursing homes (Feng, Grabowski, Intrator, & Mor, 2006), and a critical decrease in the supply of licensed and unlicensed nursing staff (U.S. General Accounting Office, 2001). Recruitment and retention efforts are not the sole solution to the national nursing home workforce shortage. Intensive efforts also need to ensure the limited supply of nursing staff is used in the most effective and efficient manner. Such effort requires attention to organizing and modifying the delivery of nursing care to ensure residents’ care needs are coordinated, communicated, supervised, and evaluated. The purpose of this study was twofold: (a) to identify and validate the distinctive components of nursing practice models (NPMs) in LTC facilities; and (b) to develop an instrument to describe and evaluate NPMs in LTC facilities.

Background

NPMs provide the framework for the design and delivery of nursing care to residents in LTC facilities and characterize the manner in which nursing staff assemble to accomplish clinical goals (Brennan & Anthony, 2000). NPMs have been referred to in the nursing literature as nursing care delivery systems, models, or strategies; modalities of nursing practice; patient care delivery systems; and nursing assignment patterns or systems (Cherry & Jacob, 2008; Huber, 2006; Koloroutis, 2004; Yoder-Wise, 2007). Often identified as primary nursing, modular nursing, team nursing, or functional nursing, NPMs are used to organize and deliver care and ensure that the required personnel are used most effectively and efficiently.

NPMs in LTC facilities are distinguished from professional practice models, as the latter is conceptualized as “supporting registered nurse control over the delivery of nursing care and the environment in which care is delivered” (Hoffart & Woods, 1996, p. 354). Professional practice models have a primary focus on the RN but acknowledge that a nurse’s practice occurs in the context of collaboration with interdisciplinary teams. Hoffart and Woods (1996) proposed that professional practice models include a governance model, a care delivery approach, as well as consideration of values, professional relationships, compensation, and rewards. The accountability of the RN is a component of an NPM in LTC facilities, but an NPM also takes into account the important collaborative roles of other licensed and unlicensed nursing and non-nursing staff in the delivery of resident care.

NPMs may significantly contribute to resident, staff, and organizational outcomes, and understanding the impact they have on these outcomes will enable nurse administrators in LTC facilities to make critical decisions on how to organize the delivery of nursing care for residents.

Literature Review

Research on NPMs has been conducted primarily in acute care hospitals and has focused on the care delivery system. Tiedeman and Lookinland (2004) analyzed four traditional models of patient care delivery: total patient care, functional, team, and primary nursing. They noted there was a large body of literature on models of care delivery; however, it was either conceptual or descriptive and lacked systematic evaluation of the care delivery models. Consequently, they found little evidence for determining which model was the most effective in regard to quality of care, cost, and satisfaction.

In contrast, knowledge regarding effective NPMs for LTC facilities is quite limited. Although several reports in the literature suggest NPMs have a positive impact on resident outcomes, only a few empirical studies examined NPMs in LTC facilities (Anderson & Hughes, 1993; Cox, Kaeser, Montgomery, & Marion, 1991; Rantz et al., 2003; Teresi et al., 1993). These studies focused on the accountability of the RN for the overall care planning and coordination for the resident and/or providing continuity with permanent assignments to nursing assistants and permanent caseloads for RNs. Other reports on NPMs in LTC facilities are either anecdotal or use a case study approach (Haff, McGowan, Potts, & Streekstra, 1988; Healy & Elliott, 1999; Patchner & Patchner, 1993; Patterson, 1987; Smith, 1991; Turkel, Tappen, & Hall, 1999). There is some evidence in these studies that NPMs in LTC facilities have improved outcomes such as individualized resident care, staff satisfaction, and clinical indicators (e.g., fewer pressure ulcers). One study found that the use of NPMs in LTC facilities would attract nurses to LTC (Robertson & Cummings, 1996). However, very few measures used in these studies had reported reliability and validity. In addition, no consistent measures were used between studies, and some studies did not report the statistical results, only global descriptions of the outcomes. The evidence to identify the essential components of NPMs in LTC facilities and their relationship to resident, staff, and organizational outcomes is simply lacking.

Only two research programs—20 years apart—have investigated the structural and contextual characteristics of NPMs (Brennan & Anthony, 2000; Munson & Clinton, 1979). Munson and Clinton (1979) proposed three major areas for what they termed a “nursing assignment pattern”: integration, continuity, and coordination. These three areas are further subdivided into 10 elements that comprise a nursing assignment pattern. The researchers developed an extensive data collection and analysis protocol to measure and index the 10 elements and influencing factors for nursing assignment patterns. Brennan and Anthony (2000) defined NPMs as “multidimensional representations of the structural and contextual features that exist in any group practice of nursing” (p. 372). They used appraisal by experts in nursing care delivery and developed a measurement strategy that could mimic expert appraisal of NPMs, resulting in an index of 24 attributes of NPMs. An analysis of these two sets of nursing assignment elements and NPM attributes indicated a developing consensus on NPM components, specifically continuity of care, accountability, and collaboration.

The two models, nursing assignment patterns (Munson & Clinton, 1979) and NPMs (Brennan & Anthony, 2000), were constructed within the context of nursing practice in an acute care hospital; yet, the elements and attributes identified through their work have relevance to LTC facilities and contribute to the theoretical perspective about how to consider the components of NPMs in LTC facilities, such as participation in unit decision making or communication between unlicensed and licensed nursing staff. However, some unique aspects of LTC facilities need to be considered for NPMs in LTC facilities. First, LTC facility residents have significantly longer lengths of stay than hospital patients. Although 20% of residents in LTC facilities spend less than 3 months in nursing homes, the average length of stay is 2.44 years (Decker, 2005). Second, compared with hospitals, LTC facilities have fewer RNs and a high proportion of unlicensed nursing staff. The average RN hours per resident day is 0.5, in contrast to 2.3 hours per resident day for unlicensed nursing staff (Harrington, Carrillo, & Blank, 2008). Finally, LTC facilities have had a long-standing focus on collaboration among the disciplines to support interdisciplinary resident assessment and care planning. These unique aspects factor into the identification of NPM components for LTC facilities.

Conceptual Model

To guide the identification of NPM components specific to LTC facilities and the development of an instrument to measure these components, a conceptual model related to NPMs was developed from the literature review, which included research relevant to American Nurses Credentialing Center magnet hospitals, as well as the first author’s previous research in, experience with, and knowledge of LTC nursing management and administration (Mueller, 2000, 2002). This model (Figure) specifies four components of NPMs for LTC facilities: accountability, decision making, continuity of care (including information and care providers), and collaboration. These same components were also identified by Reilly, Mueller, and Zimmerman (2006) as part of the process domain for a nurse staffing taxonomy for LTC facilities. Table 1 provides the initial theoretical definitions of these components.

Nursing Practice Model Conceptual Framework.

Figure. Nursing Practice Model Conceptual Framework.

Proposed Definitions of Nursing Practice Model (NPM) Components

Table 1: Proposed Definitions of Nursing Practice Model (NPM) Components

As shown in the Figure, resident characteristics influence the nursing resources, and together they influence NPMs. Other factors proposed to influence NPMs are professional development factors and unit structural support factors (i.e., leadership, environment, support services). NPMs will influence resident, staff, and organizational outcomes. This research study addressed only the portion of the conceptual model related to NPMs, which is highlighted in the Figure.

Method

Using the four components of NPMs that were derived from the literature and the first author’s experience, a systematic process was used to validate the components. Following validation, a systematic instrument development process (Waltz, Strickland, & Lenz, 2004) was used to operationalize the NPM construct on the basis of the NPM components that were validated. All components of this study were approved by the participating university’s Human Subjects Committee.

Validation of NPM Components

As previously noted in the description of the development of the conceptual model, the proposed four NPM components and associated theoretical definitions were identified in a literature review related to NPMs. To continue the process of modifying and validating the four NPM components for LTC facilities, a series of focus groups was held with nursing staff employed in LTC facilities (Morgan, 1998). The focus groups were intended to validate—and if necessary—add, eliminate, or modify NPM components and theoretical definitions that would subsequently guide the development of operational definitions and measurement items for each of the NPM components.

Direct care staff was recruited from 25 LTC facilities that were part of a consortium in a large metropolitan area by posting flyers in the facilities with the cooperation of the consortium. Payment was offered to participate in the focus group, and interested individuals could contact the researcher directly by telephone. Focus group participants had to be RNs and licensed practical nurses (LPNs) in staff nurse or nurse manager/supervisor positions, or nursing assistants (NAs). All participants had to have had 3 or more years of experience in a LTC facility.

Three focus groups were held with a total of 18 participants. Two focus groups were held with RNs (n = 8) and LPNs (n = 6), and one was held with NAs (n = 4). Five categories of questions proposed by Krueger (1998) were used to guide the development of the focus group questions for this study. The key questions developed for the focus groups centered on the four NPM components. Participants were first provided the definition of an NPM component (e.g., continuity of care provider) and were asked, “What are your thoughts and perspectives about [NPM component] as a key aspect to how nursing care is organized and delivered on nursing units in LTC facilities?” and “How have you seen or experienced [NPM component] on the nursing unit/facility in which you work?” Following discussion of the question, participants were asked to independently rate the importance of the NPM component on a 4-point Likert scale (4 = very important, 3 = moderately important, 2 = somewhat important, 1 = not important). The rating was done on a piece of paper that included the NPM component and definition. An example related to the component of continuity of care was as follows: “When you think about organizing and delivering nursing care to residents on a nursing unit, how important is it to have adequate and relevant information about the resident available, used, and transferred among persons involved in the care of the residents?”

The rating forms were collected and immediately collated. The aggregate results were reported back to the group. If the results were unanimous, no further discussion took place—this was the case most often. If the results were not unanimous, the group was asked to continue to discuss the component, followed by a second rating exercise. In all cases, consensus was reached after the second rating exercise. After each NPM component was discussed and rated during the 2-hour focus group, the group members were asked whether they thought other important components should be considered for the organization and delivery of nursing care in LTC facilities.

The focus groups were conducted by the researcher (C.M.). The discussion during the focus groups was audio recorded, with appropriate informed consent obtained from the respondents. A research assistant took notes to identify the position of the focus group participant who was talking (i.e., RN, LPN, NA). The audio recordings were transcribed, and the research assistant matched the focus group notes with the transcriptions by identifying the respondent’s position. The researcher and research assistant independently reviewed the transcripts to determine the following:

  • Adequate evidence to validate the four components of NPMs. Adequate evidence was based on the frequency of comments to support the components, the intensity of the comments (e.g., strong, definitive statements), and extensiveness (i.e., same theme reiterated by more than one respondent).
  • Adequate evidence to modify the definition of any one or more of the four NPM components.
  • Identification of additional components for NPMs as evidenced by discussion of the four components and the introductory and final questions asked of the focus group participants.
  • Identification of trends related to NPM components by position of respondent (i.e., RN, LPN, NA).

The independent reviews were then compared to determine consensus regarding interpretation of the above.

Development and Modification of Data Collection Instruments and Protocols

Content Validity. Using the findings from the focus groups and literature review, items were developed for each of the components. Content validity of the items was assessed using two experts in LTC nursing administration and management. An index of content validity was calculated for each of the NPM components (Waltz et al., 2004).

Burden, Feasibility, and Clarity. Following establishment of content validity, the measurement items were used to create the Nursing Practice Models Questionnaire (NPMQ). In addition, facility, unit, and staff demographic questionnaires were developed. Two kinds of response sets were created for the NPMQ. The first was yes/no measure and the second was a 3-point Likert scale (always/almost always, sometimes, rarely/never). Because the NPMQ would be completed by both unlicensed and licensed nursing staff, the two response sets allowed choice in determining which would be easier and provide the most complete questionnaires from respondents. A Likert scale with more than three responses was not used because it was determined it could be too complex for NAs, especially for whom English was a second language.

Two versions of the NPMQ were developed—one for each response set. The items associated with continuity of care, decision making, and collaboration used these two response sets. The NPM component of accountability used a different response set. The purpose of the accountability items was to determine who was primarily responsible for each of the activities described in each item (e.g., completing focused resident assessments, supervising care that was delegated to unlicensed staff). The accountability items required the respondent to identify whether it was the RN, LPN, or both who was primarily responsible for the activity. Only RNs and LPNs were to complete the items associated with the accountability component.

Three sets of demographic questionnaires were developed: direct care nursing staff demographics, nursing unit demographics, and facility demographics. The two versions of the NPMQ and the three demographic questionnaires were evaluated by three LTC facility nurse administrators for clarity and burden. Clarity was assessed as follows:

  • Are the questions clearly written?
  • Will the items be understood by nursing staff, particularly NAs?
  • Do you have recommendations for any changes in the wording of the questionnaire items?
  • Are the response items in both versions clear, and will nursing staff, particularly NAs, know what is meant by the response items?
  • Do you have any recommendations for improving the clarity of the response items?

Burden was assessed by asking the anticipated time nursing staff would need to complete the NPMQ, including the demographic form.

The two versions of the NPMQ were then pretested in two facilities, and the versions were randomly distributed to all respondents. In addition, a one-page form titled “Feedback on the Questionnaire” was included with the NPMQ. Respondents were asked to determine approximately how many minutes it took to complete the questionnaire, whether any items on the questionnaire were confusing or difficult to understand, and for suggestions for making those items easier to understand or less confusing. A total of 111 direct care nursing staff from 10 nursing units in the two facilities completed the questionnaire.

Pilot Test of Study Instruments and Data Collection Protocols

The NPMQ, demographic questionnaires, and protocols to collect these data in LTC facilities were tested further to evaluate and establish their validity and reliability, specifically construct validity and internal consistency. All nursing facilities (N = 162) within a 50-mile radius of the university were invited to participate in the study. Fifteen nursing facilities returned a postcard indicating their interest in participating in the study. Ten facilities were stratified according to proprietary status and number of beds to ensure representation of different kinds of nursing facilities. Two facilities were excluded from the sample due to their unique characteristics (i.e., small unit of sub-acute patients, facility that provides care to younger spinal cord injury patients). As data collection progressed, it appeared there was a possibility that the 10 facilities may not provide the number of questionnaires needed for the factor analysis, as 100 cases plus at least 5 cases per variable were required (Norman & Streiner, 2007). The three remaining facilities not originally selected were invited to participate in the study. These three facilities represented the ≥150-bed category. The data from the two facilities that participated in the pretesting of the NPMQ were also included in the sample, as no changes were made to the NPMQ following pretesting. A total of 15 facilities comprised the sample and included 65 nursing units and 508 direct care nursing staff (RNs, LPNs, and NAs).

The facility demographic form was completed by the director of nursing or his or her designee. Each unit demographic form was completed by the nurse manager or supervisor of the unit. Data collection occurred over a 10-week period.

Data Analysis

Descriptive statistics for interval data were presented as either means with standard deviations or medians and ranges, depending on distribution of the data. Categorical data were described with frequencies. Construct validity of the NPMQ was assessed using an exploratory factor analysis on the 3-point Likert scale version of the tool. To assess the construct validity of the NPMQ, factor analysis was done on the 32 items associated with decision making, continuity of care, and collaboration. The items associated with the NPM component of accountability were not evaluated using factor analysis because of the way they were scored on the NPM questionnaire (RN, LPN, or both). The correlation matrix between all items was assessed for items that were correlated with all other items at a value of r < 0.3, and those were removed before the actual factor analysis was performed. During the initial factor analysis, Bartlett’s test of sphericity, the Kaiser-Meyer-Olkin (KMO) measure of sampling adequacy, and the determinant of the correlation matrix were used as indication of the appropriateness of the data for factoring. Factors were extracted using the principle components method. Factors were identified using eigenvalues >1 and the discontinuity of the slope of the scree plot. A varimax rotation was used to help interpret factors that were not expected to be highly correlated. Items were considered to belong to a specific factor if their loading was >0.4 with low loadings on other factors. Following these procedures, each factor was identified and compared with the hypothesized NPM components. Individual items not loading on any factor at 0.4 or greater were eliminated from the NPMQ and the analysis was re-run. Cronbach’s alpha coefficients were calculated for each resulting factor from the final analysis (Polit, 1996).

Results

Validation of NPM Components

The results from the three focus groups provided strong support for the four NPM components. However, the focus group participants clearly differentiated between the two subcomponents of continuity of care—information continuity and care provider continuity. According to the focus group participants, these two subcomponents seemed very distinct and different, even though they both achieved the same purpose. Therefore, these two subcomponents were identified as two distinct components. The focus group participants did not identify any other themes that would suggest the addition of other components. The analysis of the transcript documents from the focus groups did not indicate any differences in how RNs, LPNs, and NAs viewed the four NPM components. For example, both NAs and licensed nurses strongly agreed that nursing home residents should have the same nurse and NA assigned to them to ensure continuity of care.

The ratings for the NPM components were quantified by determining the percentage of focus group respondents who rated the NPM components very important, moderately important, somewhat important, and not important. More than 90% of the respondents rated each component as very important. The analysis of the focus group discussion and the ratings of the NPM components provided support for five NPM components: accountability, decision making, continuity of information, continuity of care providers, and collaboration.

Development and Modification of an Instrument to Measure Components of NPMs in LTC Facilities

Content Validity. Forty-two items related to the NPM components were developed by the researcher for the NPM questionnaire. These items were evaluated by two content experts to determine whether an individual item supported the NPM component it was intended to measure. A content validity index (CVI) was calculated based on the ratings from the experts (Waltz et al., 2004). The CVIs for all components were 0.92 or greater (accountability = 1.00, decision making = 1.00, continuity of care = 0.923, collaboration = 1.00). The CVI for all of the measurement items (i.e., the entire questionnaire) was 0.976. The results of the CVI indicated strong support for the NPM items and their associated components. The items associated with the NPM component of accountability were based on the 2005 Minnesota Nurse Practice Act and were also validated with a staff consultant from the Minnesota State Board of Nursing.

Burden, Feasibility, and Clarity. The NPMQ was reviewed by the three nurse administrators for burden, feasibility, and clarity and resulted in no item deletions or additions. Several items had wording changes to improve clarity on the basis of suggestions from the nurse administrators.

When the NPMQ, using the two different response sets, was pretested with 111 licensed (n = 42) and unlicensed (n = 69) nursing staff from two LTC facilities, the respondents indicated it took an average of 12 minutes to complete the NPMQ and demographic form (range = 3 to 30 minutes). Thirteen respondents provided feedback on several items, but the feedback was not specific or consistent. Occasionally the feedback was not relevant. The 3-point Likert scale version of the NPMQ did not seem to cause any difficulties for the respondents, and because this version of the NPMQ provided opportunity for more variability in responses, it was the version selected to pilot test the NPMQ.

The version of the NPMQ to be tested in the pilot test had 46 items with five subscales: accountability (14 items); decision making (11 items); continuity of information (13 items); continuity of care providers (5 items); and collaboration (3 items). The items associated with the NPM component of accountability were completed only by RNs and LPNs. The reason the items increased from 42 to 46 is because some of the items were stated twice, once for licensed nursing staff and once for unlicensed nursing staff (i.e., “NAs provide information for the Minimum Data Set [MDS] resident assessments”; “Licensed nurses provide information for the MDS resident assessments.”).

Pilot Test of Study Instruments and Data Collection Protocols

The NPMQ was subjected to further validity and reliability testing, as specified above. As described in the Method section, 15 LTC facilities composed of 65 nursing units and 508 nursing staff participated in the study. Table 2 provides the demographic information for the study participants.

Demographic Characteristics of Respondents

Table 2: Demographic Characteristics of Respondents

Factor analysis was performed on the items associated with decision making, continuity of information, continuity of care providers, and collaboration. The determinant of the matrix was >0.0001, indicating that the correlation matrix was not an identity matrix. A KMO of 0.81 indicated adequate sampling, and Bartlett’s test of sphericity was significant, indicating homogeneity of variance. Four items did not load on any factor. Five items that loaded on a factor were eliminated because they did not provide any common theme. Factor analysis was rerun without those five items, resulting in four factors that gave the most stable results explaining 50.6% of the variance. The internal consistency for the four factors ranged from 0.69 to 0.84. Table 3 provides the results of the factor analysis and the Cronbach’s alpha coefficients for each of the factors. Table 4 shows the differences between the hypothesized NPM components and the components identified through factor analysis.

Factor Analysis of the Nursing Practice Model Questionnaire

Table 3: Factor Analysis of the Nursing Practice Model Questionnaire

Nursing Practice Model Components Before and After Factor Analysis

Table 4: Nursing Practice Model Components Before and After Factor Analysis

The subscale related to the NPM component of accountability had 14 items. According to the Minnesota Nurse Practice Act (2005), 7 of the items were the responsibility of only the RN. This portion of the NPMQ was completed only by RNs and LPNs (n = 175). Listed below are the 7 items that are the responsibility of the RN and the percentage of respondents who indicated that only the RN is primarily responsible for the activity:

  • Coordinating completion of the MDS (62%).
  • Developing and/or revising residents’ care plans on the basis of assessments (23%).
  • Identifying problems from the resident assessments that should be addressed on the care plan (17%).
  • Delegating responsibilities and tasks to unlicensed personnel to carry out the residents’ care plans (9.7%).
  • Monitoring residents’ care to evaluate whether the plan of care is effective (6.9%).
  • Supervising and overseeing care that was delegated to unlicensed staff (5.7%).

These results indicate that practice in LTC facilities is not consistent with the Minnesota Nurse Practice Act (2005). The results do not negate the validity of the accountability subscale. The final version of the NPMQ has five subscales with 37 items (Table 5). The complete version of the NPMQ is available on request from the first author.

Nursing Practice Model Questionnaire Components and ItemsNursing Practice Model Questionnaire Components and Items

Table 5: Nursing Practice Model Questionnaire Components and Items

Discussion

The purpose of this study was to identify and validate components of NPMs in LTC facilities and develop an instrument to describe and evaluate NPMs in LTC facilities. This study provides good preliminary evidence for the components of NPMs in LTC facilities related to content validity, internal consistency, and construct validity. Two of the components had an internal consistency slightly below 0.70 (0.68 to 0.69), which is considered the standard for determining adequate internal consistency for an instrument (Polit, 1996).

Five NPM components were identified and validated through this study and include: accountability, decision making, informal continuity of information, formal continuity of information, and continuity of care providers. The NPMQ is a 37-item questionnaire with five subscales. A 3-point Likert response set proved to be satisfactory in obtaining variability among nursing units and facilities, and it was not difficult for the direct care nursing staff to complete. A limitation of this study is that it was conducted in one metropolitan area in one state, and the results may not be generalizable to LTC facilities in rural communities or other areas of the country. Further, the study’s response rate was 10% and included only those who volunteered to participate.

The original proposed NPM component of continuity of care turned out to be a more complex component than originally conceptualized. The initial definition of continuity of care had two subcomponents: continuity of information and continuity of care providers. The continuity of information subcomponent was further distinguished from the factor analysis by identifying both informal and formal information that is transferred among nursing staff. Table 5 provides the items associated with each of these components.

The study results regarding the NPM component of accountability indicated that the roles of RNs and LPNs appear to be interchangeable in LTC facilities. Less than 10% of the respondents indicated that only RNs delegated responsibilities and tasks to unlicensed personnel to carry out the residents’ care plans. Yet the RN delegation process, which includes determining appropriate tasks to be delegated and to whom, supervising performance, evaluating delegated tasks, and reassessing and adjusting the care plan, represents the primary mechanism to ensure that professional nursing standards of care reach the bedside. This finding uncovered an important area for further research, specifically examining the scope of practice for RNs and LPNs in LTC facilities and its relationship to resident quality outcomes.

Recommendations for Research and Conclusion

As noted in the conceptual model, the components of NPMs are supported by leadership, the environment, and support services. Further research is needed to examine the influence of these factors on the components of NPMs. For example, how would the leadership skill and style of a nurse administrator influence the accountability of RNs?

The nursing home culture change movement is beginning to change the way some LTC facilities provide care and services to residents. Nursing home culture change is about the transformation of nursing homes from an acute care medical model that functions according to staff-directed schedules and routines to a consumer- or resident-directed model that functions according to the preferences and routines of the residents (Pioneer Network, n.d.). Nursing home culture change challenges the roles and functions of nursing home staff, calls for changes in the physical environment and structure of the organization, and requires drastic changes in leadership practices. Components of the NPM that can be most affected by this philosophical approach to care for nursing home residents are continuity of care providers and decision making. This study was conducted in LTC facilities that had traditional organizational structures, roles for nursing staff, and routines and schedules for residents. The NPMQ should be validated in facilities that are engaged in nursing home culture change.

The NPMQ should also be further tested with other samples (e.g., national sample, other states), as well as tested regarding the internal consistency of the NPM components. The NPMQ should be used to profile NPMs in LTC facilities to obtain descriptive data on NPMs in such settings. Given the respectable validity and reliability of the NPMQ, it can be used to examine relationships between NPM components and staff, resident, and organizational outcomes in LTC facilities. Studies to determine whether interventions to strengthen one or more components of the NPM improve resident, staff, and organizational outcomes are also recommended. Finally, the NPMQ can be used by nurse administrators in LTC facilities as a decision-making tool to characterize and diagnose their NPMs and modify aspects of the NPM on their nursing units and/or facility to improve resident, staff, and organizational outcomes.

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Proposed Definitions of Nursing Practice Model (NPM) Components

NPM Component Definition
Accountability The RN’s responsibility in and authority over the assessment, planning, implementation, and evaluation of nursing care for residents.
Decision making Active participation of nursing staff in making decisions about their work, their work environment, and resident care.
Continuity of care Seamless provision of health care services for a resident when they are on the nursing unit and through transition to the next care setting. Continuity of care can be achieved when adequate and relevant information about the resident is available, used, and transferred among individuals involved in the care of the resident (i.e., continuity of information). Continuity of care can also be achieved when there is a consistent nurse or group of nursing staff coordinating and providing care to the resident (i.e., continuity of care provider).
Collaboration The extent to which nursing staff and other interdisciplinary staff work together to identify and meet resident needs.

Demographic Characteristics of Respondents

Variable RNs (n =64) Licensed Practical Nurses (n =111) Nursing Assistants (n =312) Total (N =508a)
Women (%) 93.7 91.8 76.9 82.4
Age, in years (SD) 46.3 (10.8) 42.4 (9.8) 36.6 (12.3) 39.5 (12.1)
Race/ethnicity (%)
  White/Caucasian 87.5 83.5 45.4 58.7
  Black/African American 4.7 11 41 30.3
  American Indian/Alaskan Native 1.6 2.8 2.4 2.2
  Hispanic/Latino 0 0 2.7 1.8
  Native Hawaiian/other Pacific Islander 0 0 0.7 0.4
  Other 6.3 2.8 7.8 6.5
Years working in facility (SD) 9.9 (8.7) 6.1 (7.0) 5.7 (6.9) 6.5 (7.4)
Years working in long-term care (SD) 15.6 (10.1) 13.8 (9.2) 9.28 (9.0) 11.3 (9.6)

Factor Analysis of the Nursing Practice Model Questionnaire

Item Decision Making Informal Continuity of Information Formal Continuity of Information Continuity of Care Providers
Participate in determining budget needs for the nursing unit 0.76
Participate in selecting their unit manager 0.76
Participate in interviewing and selecting RNs, licensed practical nurses (LPNs), and nursing assistants (NAs) 0.75
Participate in determining work responsibilities for RNs, LPNs, and NAs 0.66
Participate in developing monthly staffing schedules 0.66
Participate in deciding how the nursing unit will be staffed each shift 0.65
Participate in recruitment of other nursing staff to work in the facility or on the unit 0.61
Participate in developing the standards of care or policies that will be used 0.61
Participate in determining equipment and supply needs for the unit 0.55
Licensed nurses and NAs usually exchange information about residents’ needs, concerns, and observations at the beginning of the shift 0.66 0.47
Licensed nurses and NAs usually exchange information about residents’ needs, concerns, and observations throughout the shift 0.66
Communication between nursing staff about resident needs is good 0.65
Licensed nurses and NAs usually exchange information about residents’ needs, concerns, and observations at the end of the shift 0.62
Licensed nurses and NAs do not exchange information about residents’ needs, concerns and observations 0.62
NAs attend and participate in resident care conferences 0.70
Nursing staff caring for residents attend and participate in shift reports at beginning of shift 0.41 0.66
Nursing staff caring for residents attend and participate in shift reports at end of shift 0.66
Licensed nurses attend and participate in resident care conferences 0.59
The same NAs consistently work each shift 0.75
The same LPNs consistently work each shift 0.75
The same RNs consistently work each shift 0.67
NAs have the same group of residents 0.63
I am assigned to only work on my nursing unit 0.46
Variance explained 23.2 12.4 9.1 5.8
Cronbach’s alpha coefficient 0.84 0.72 0.68 0.69

Nursing Practice Model Components Before and After Factor Analysis

Hypothesized Components and Items Components and Items Identified Through Factor Analysis
Decision making (11 items) Decision making (9 items) (Factor 1)
Continuity of information (13 items) Informal continuity of information (6 items) (Factor 2) Formal continuity of information (5 items) (Factor 3)
Continuity of care providers (5 items) Continuity of care providers (5 items) (Factor 4)
Collaboration (3 items)

Nursing Practice Model Questionnaire Components and Items

Component Item
Formal continuity of information

On my nursing unit, nursing assistants (NAs) attend and participate in resident care conferences.

On my nursing unit, licensed nurses attend and participate in resident care conferences.

On my nursing unit, all nursing staff caring for residents attend and participate in shift report at the beginning of the shift.

On my nursing unit, all nursing staff caring for residents attend and participate in shift report at the end of the shift.

Continuity of care provider

On my nursing unit, the same RNs consistently work each shift.

On my nursing unit, the same licensed practical nurses (LPNs) consistently work each shift.

On my nursing unit, the same NAs consistently work each shift

Informal continuity of information

On my nursing unit, licensed nurses and NAs usually exchange information about residents’ needs, concerns, and observations at the beginning of the shift.

On my nursing unit, licensed nurses and NAs usually exchange information about residents’ needs, concerns, and observations at the end of the shift.

On my nursing unit, licensed nurses and NAs usually exchange information about residents’ needs, concerns, and observations throughout the shift.

On my nursing unit, licensed nurses and NAs usually do not exchange information about residents’ needs, concerns, and observations.

On my nursing unit, the communication between nursing staff about the needs of residents is good.

Continuity of care providers

On my nursing unit, NAs have the same group of residents.

I am assigned to only work on my nursing unit.

Decision making

On my nursing unit, nursing staff participate in developing the monthly staffing schedule.

On my nursing unit, nursing staff participate in deciding how the nursing unit will be staffed each shift.

On my nursing unit, nursing staff participate in developing the standards of care or policies that will be used. For example, nursing staff determine the kinds of toileting programs or ambulation programs that will be used.

On my nursing unit, nursing staff participate in determining the work responsibilities of nursing staff (RNs, LPNs, NAs).

On my nursing unit, nursing staff participate in the recruitment of other nursing staff to work in the facility or on the unit.

On my nursing unit, nursing staff participate in interviewing and selecting RNs, LPNs, and NAs to work on the unit.

On my nursing unit, nursing staff participate in selecting their unit manager or coordinator.

On my nursing unit, nursing staff participate in determining budget needs for the nursing unit.

On my nursing unit, nursing staff participate in determining equipment and supply needs for the unit (e.g., incontinent pads and briefs, lifts).

Accountability

Completing focused resident assessments (e.g., change in condition, fall risk assessments, skin integrity assessments)

Completing some or all of the Minimum Data Set (MDS)

Coordinating completion of MDS assessments

Identifying problems from the resident assessments that should be addressed on the care plan

Developing and/or revising residents’ care plans based on assessments

Contributing to the development and/or revision of the residents’ care plans

Delegating responsibilities and tasks to unlicensed personnel to carry out the residents’ care plans

Monitoring residents’ nursing care provided by others

Monitoring residents’ care to evaluate if the plan of care is effective

Supervising and overseeing the care that was delegated to unlicensed staff

Administering medications

Administering treatments

Documenting the effectiveness of care in the resident’s medical record

Documenting resident assessment data (e.g., change in condition, vital signs)

Authors

Dr. Mueller is Associate Professor and Chair, Adult and Gerontological Health Co-operative Unit, and Ms. Savik is Senior Research Associate, University of Minnesota, School of Nursing, Minneapolis, Minnesota.

The authors disclose that they have no significant financial interests in any product or class of products discussed directly or indirectly in this activity. The project described in this article was supported by the Agency for Healthcare Research and Quality (AHRQ) grant AHRQ 1R03 HS13773-01, and its contents are solely the responsibility of the authors and do not necessarily represent the official views of the AHRQ.

Address correspondence to Christine Mueller, PhD, RN, FAAN, Associate Professor and Chair, Adult and Gerontological Health Co-operative Unit, University of Minnesota, School of Nursing, 5–140 WDH, 308 Harvard Street SE, Minneapolis, MN 55455; e-mail: cmueller@umn.edu.

Received: January 20, 2009
Accepted: July 21, 2009
Posted Online: December 31, 2009

10.3928/19404921-20091207-97

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