Chapter 19. Care Models 

Bonnie M. Jennings 

Background 

The organization of care delivery is determined by a variety of factors such as economic 

issues, leadership beliefs, and the ability to recruit and retain staff. Ideally, evidence of the effect 

of care models on quality and patient safety would also be a major factor in decisionmaking. 

Historically, four traditional care models have dominated the organization of inpatient 

nursing care. Functional and team nursing are task-oriented and use a mix of nursing personnel; 

total patient care and primary nursing are patient-oriented and rely on registered nurses (RNs) to 

deliver care.1, 2 In the late 1980s, a number of nontraditional nursing care delivery models 

emerged that use various mixes of licensed and unlicensed nursing personnel.3–5 

Care models do not exclusively pertain to the organization of nursing care, however, or the 

inpatient setting. Models have been examined for medical housestaff,6 pharmacy services,7 and 

social workers.8 They have been considered for ambulatory care,9–12 home care,13–15 and nursing 

homes.16 Care models also exist for specific patient populations such as elderly patients,17–20

people with mental health needs,21 and individuals with chronic conditions22 to include disease 

management models23, 24 and the use of technology.25 

Research Evidence 

Despite the interest in a variety of care models, it is difficult to discern which models work 

best. Neither the traditional nor the nontraditional inpatient nursing care models have been 

evaluated rigorously for their effects on patient safety.2, 4, 26 Emerging models from other care 

disciplines, other settings, and particular patient populations are also lacking rigorous empirical 

assessments of their relationship to patient safety. 

A number of investigations examining care models addressed nurses’ perceptions of the care 

model.1, 27–38 Only two investigations combined the nurses’ perceptions with patient safety 

measures.39, 40 

Several studies did not meet the criteria for inclusion in this review, largely due to weak 

designs. Of these, some reported pilot data,6, 7, 13, 24, 41, 42 some were quality-improvement 

projects,14, 17, 43 and others used qualitative methods.32, 36,44–48 Like the quantitative studies, the 

rigor of the qualitative investigations varied. However, these qualitative studies illuminate 

important aspects of care models not evident in quantitative investigations. For example, 

Ingersoll32 and Redman and Jones36 were among the first investigators to assess the effects of 

patient-centered care models on nurse managers. The data from both of these studies expose the 

pressure and role confusion experienced by nurse managers. Subsequently, a quantitative 

investigation found nurse managers experienced a high level of emotional exhaustion, a key 

component of burnout.49 

Among the quantitative studies of care models included in the evidence table, only one used 

a design that combined systematic review and meta-analytic techniques.23 No randomized 

controlled trials were identified. The remaining seven studies used Level 3 designs. In two of 

1 
Patient Safety and Quality: An Evidence-Based Handbook for Nurses

these studies, large databases were used to examine different care models for home-based longterm care15 and mental health services.21 

All five studies of nursing care models meeting inclusion criteria focused on acute care work 

redesigns in which the mix of nursing personnel was altered in some way. For each of these five 

investigations, data were reported from only one hospital.39, 40, 50–52 Of these studies, one 

evaluated changes in care delivery models at one university teaching hospital with two campuses 

in the same city.39 The remaining studies were smaller in scale focusing data collection on 

one,50, 51 two,52 or three units40 in the same facility. Most often, measurements were done at three 

points in time—pre-implementation, and at 6 and 12 months after the model was 

introduced.39, 40, 52 

Evidence-Based Practice Implications 

The eight studies in Table 1 illustrate two main clusters of research. The first pertains to 

studies of inpatient nursing care models. Statistically discernible differences were rarely evident, 

and when they were, there was no clear pattern to guide practice.39, 40, 50–52 For example, there 

were statistically fewer falls reported in two studies after units implemented care models using 

fewer RNs, presumably because there were more staff to assist patients.50, 51 Fewer medication 

errors were detected in only two reports.39, 52 However, quite unexpectedly and counter 

intuitively, postoperative pain scores were statistically higher on a unit after the number of RNs 

increased.50 

There were no consistent patterns visible in findings among the studies that followed changes 

in the care model over time—before implementation and at 6 and 12 months.39, 40, 52 However, 

the studies with multiple measurements showed that initial indicators of success were rarely 

sustained over time. This is similar to results from the study by Greenberg and colleagues21 in 

which most positive effects of change lasted only one year. Despite the growing number of work 

redesign studies, the findings are too disparate even among those with stronger designs to offer a 

clear direction about practice changes to improve patient safety. 

The second cluster of care model studies consists of three investigations that were conducted 

by other disciplines.15, 21, 23 These studies demonstrate that the interest in determining which care 

models operate best is not isolated to nursing. The improved ability to detect statistical 

differences in these models may derive from their large sample sizes, their statistical techniques, 

or their use of different outcomes. The systematic review and meta-analysis of disease 

management programs for individuals with depression offers the strongest evidence for guiding 

care delivery.23 With only one study of consumer-directed home-based long-term care,15 and one 

of service-line delivery of mental health services,21 practice changes for these areas should be 

considered carefully. 

Research Implications 

We actually know very little about the relationship between care models and patient safety. 

Randomized controlled trials (RCTs) might contribute evidence that would help investigators, 

administrators, and policy makers sort through the confusion. RCTs would be particularly 

difficult to conduct, however, given the need to have longitudinal data. The rapidly changing 

health care environment is not conducive to such endeavors. 

2
Care Models

The most glaring need relates to clarifying the work that needs to be done for patients and 

then determining which clinicians are best suited to provide it. Looking only at the work of 

nurses, which has dominated studies of care models in acute care settings, fails to consider 

nonnursing staff who are critical to the patient care mission. 

We also know very little about care models that promote patient safety in outpatient settings, 

home care, or long-term care. These are areas that remain to be explored. 

Conclusion 

Care delivery models range from traditional forms, such as team and primary nursing, to 

emerging models. Even models with the same name may be operationalized in very different 

ways. The rationale for selecting different care models ranges from economic considerations to 

the availability of staff. What is glaring in its absence, however, is the limited research related to 

care models. Even more sparse is research that examines the relationship between models of care 

and patient safety. Ideally, future studies will not only fill this void, but the models tested will be 

developed based on a comprehensive view of patient needs, taking the full complement of 

individuals required to render quality care into account. 

Search Strategy

Both MEDLINE® and CINAHL® databases were searched from 1995 to 2005 to identify 

research-based articles published in the English language that were pertinent to this review. 

Search terms were identified with the guidance of a reference librarian. The term “care models” 

was not a search option in CINAHL®. Therefore the CINAHL® search terms included “care 

delivery modules,” “nursing care delivery systems,” and “care modules.” The MEDLINE®

search was based on two terms, “care models” and “organizational models.” Together, these 

searches yielded 549 citations, 55 in CINAHL® and 494 in MEDLINE®. 

The abstracts for each of the 549 citations were reviewed. From this assessment it was 

determined that 82 of the articles were sufficiently focused on nursing or patient care models and 

should be considered further. Most of the 467 papers that were omitted used the word “model” in 

their title, but the work was not related to care models per se. For example, articles about medical 

management models were not used in this review. Additionally, a number of papers addressed 

topics with no discernible connection to care models (e.g., life support decisions for extremely 

premature infants). 

The 82 articles were located and carefully read. As a result, 31 additional papers were 

omitted from the actual analysis. Reasons for these omissions included the lack of sufficient 

detail about the study, duplicate publications, and studies of advanced practice nurses. This left 

51 articles for consideration in this review. 

Author Affiliations 

Bonnie M. Jennings, D.N.Sc., R.N., F.A.A.N., colonel, U.S. Army (Retired), and health care 

consultant; e-mail: bmjennings@cox.net. 

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Patient Safety and Quality: An Evidence-Based Handbook for Nurses

Acknowledgment 

Tremendous gratitude is expressed to the staff of the Armed Forces Medical Library for their 

considerable support of this work. They conducted the database searches and assisted in 

acquiring numerous papers considered in this review. 

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6
Table 1. Evidence Table for Care Models 

Source Safety Issue 

Related to Clinical Practice

Design Type

Study Design, Study Outcome Measure(s)

Study Setting & Study Population 

Study Interventio

Barkell 200250 Inpatient nursing 

work redesign 

Pretest (January–June 1999) and post-test (January–June 2000) (6) 

Design: Level 3 Patient outcomes: pneumonia, urinary tract infection (UTI), postoperative pain perception (Level 2), patient satisfaction 

A surgical unit in a 508-bed teaching hospital in the Midwest, all patients under DRGs 148 (major small and large bowel procedures with comorbidities or complications) & 149 (bowel resection without complications); 59 patients pre-, 37 patients post; 59% female pre- and post 

Total patient care. this intervention, thratio of RNs to unlicensed assistivpersonnel increaseas compared to the ratio in the previoumodel of team nursing. The total budgeted full-time employees decreased with the total patient care model. 

Benjamin 200015 Home-based longterm care Cross-sectional (4) Design: Level 3 Patient outcomes: 

safety (physical and psychological risk, sense of security), unmet needs (activities of daily living) (Level 2), patient satisfaction 

In-Home Supportive Services (IHSS) program in California; 1,095 IHSS Medicaid beneficiaries with disabilities in professional agency models (PAMs) and consumer-directed models (CDMs): about half the recipients were over age 65 (50% PAM, 54% CDM), most were female (77% PAM, 70% CDM); CDM recipients had more functional impairments 

Professional agencmodel vs. consumdirected model 

7
8

Source Safety Issue Related to Clinical Practice Design Type Study Design, Study Outcome Measure(s) Study Setting & Study Population Study InterventioGreenberg 200321 Changed organizational structure Nonrandomized trial (3) Design: Level 3 Patient outcomes: continuity of care, readmission (Level 2) 139 Veterans Administration Medical Centers; facility-level data for patients receiving mental health services over a 6-year period Service-line organization (interdisciplinary) v

profession-based leadership 

Grillo-Peck and Risner 199551 Inpatient nursing work redesign Pretest (January– June 1992) and post-test (January–June 1993) (6) Design: Level 3 Patient outcomes: falls, medication errors, procedure errors, nosocomial infections (Level 2), length of stay A neuroscience unit in an 800-bed not-for- profit hospital in Ohio, all patients under DRG 14 (cerebrovascular disease excluding transient ischemic attack): 71 patients pre-, 85 patients post; 56% female pre-, 55% post Nursing partnershi

model (fewer RNsmore unlicensed assistive personne
9

Source Safety Issue 

Related to Clinical Practice

Design Type

Study Design, Study Outcome Measure(s)

Study Setting & Study Population 

Study Interventio

Heinemann 199652 Inpatient nursing work redesign Nonrandomized trial with the same 

variables measured at 3 points in time using different patients (6 months before the change, 6 and 12 months after the change) (3) 

Design: Level 3 Patient outcomes: falls, medication errors, intravenous (IV) infections (Level 2), patient satisfaction 

A 518-bed private, notfor-profit hospital in Florida, all patients on two randomly selected medical-surgical units; pilot unit had 36 beds for general surgery/ trauma patients (

M

patient days for a 6-month period = 5,477), control unit had 34-beds for orthopedic/trauma patients (

M patient days 

for a 6-month period = 4,654). 

Partners in patient care (PIPC)—experimental (pilotunit; Total patient care—control unit. 

NeumeyerGromen 200423 Models of care for patients with 

depression 

Systematic review (11) and metaanalysis (1) 

Design: Level 1 Patient outcomes: depression severity (Level 1), adherence to treatment regimen, (Level 2), patient satisfaction 

Only randomized controlled trials published from 1992 to 2002; 10 studies met the inclusion criteria; patients had a mean age of 43 years, 71% were women, and about 70% were white, 75% were diagnosed with major depression 

Disease management programs (DMP) to implement guidelindriven care 
10

Source Safety Issue Related to Clinical Practice Design Type Study Design, Study Outcome Measure(s) Study Setting & Study Population Study InterventioSeago 199939 Inpatient nursing work redesign Cross-sectional, same variables measured at 3 points in time using different patients (6 months before the change, 6 and 12 months after the change) (4) Design: Level 3 Patient outcomes: medication errors, falls, pressure ulcers, (Level 2), patient satisfaction A large university teaching hospital with two campuses: patient days—30,462 at time 1, 29,584 at time 2, 29,210 at time 3 Change in care model from primar

care to patient- focused care 

Tourangeau 199940 Inpatient nursing work redesign Nonrandomized trial with the same variables measured at 3 points in time using different patients (6–7 months before the change, 6 and 12 months after the change) (3) Design: Level 3 Patient outcomes: IV therapy outcomes, falls, medication incidents, call bell usage A 258-bed acute care community hospital in Toronto; all patients on three medical-surgical units; the experimental units had 57 beds (general medicine/surgery) and 70 beds (medicine/geriatric rehabilitation); the control unit had 38 beds (postcoronary) Unlicensed assistiv

personnel (UAP)-Rpartnership model two experimental units; Total patient care with an all-RN staff on the control unit