Beyond ‘doing’: Supporting clinical leadership and nursing practice in aged care through innovative models of care

Lorraine Venturato
Research Centre for Clinical and Community Practice Innovation, Griffith University, Nathan QLD

Liz Drew
Strategy Advisor – Residential Aged Care, RSL Care, Brisbane QLD

PP: 157 - 170

Abstract

Contemporary health care environments are increasingly challenged by issues associated with the recruitment and retention of qualified nursing staff. This challenge is particularly felt by residential aged care providers, with registered nurse (RN) numbers already limited and resident acuity rapidly rising. As a result, aged care service providers are increasingly exploring creative and alternative models of care. This article details exploratory research into a pre- existing, alternative model of care in a medium sized, regional residential aged care facility. Research findings suggest that the model of care is complex and multi-faceted and is an example of an integrated model of care. As a result of the implementation of this model of care a number of shifts have occurred in the practice experiences and clinical culture within this facility. Results suggest that the main benefits of this model are 1) increased opportunities for RNs to engage in clinical leadership and proactive care management; 2) improved management and communication in relation to work processes and practices; and 3) enhanced recruitment and retention of both RNs and care workers.

Keywords

aged care, nursing, staffing, retention, workforce, model of care

Article Text

Despite evidence linking qualified, professional health care providers to quality patient outcomes (Zhang, Unruh, Liu & Wan, 2006; Mueller, 2002), the reality for contemporary health care environments is shaped by demand issues that far outweigh supply (Martin & King, 2008). This is particularly so in aged care, where the shortage of nursing professionals is heavily felt amongst a client population with multiple, complex, co-morbidities and increasing frailty (Australian Institute of Health and Welfare [AIHW], 2009; 2008; Martin & King, 2009).

While there have been many reasons put forward for aged care's lack of appeal, the fact remains that recruiting and retaining registered nursing staff in aged care is problematic. At the same time, aged care services are facing tightening regulations, funding challenges and an increasing demand for high quality care (Hogan, 2004). Many facilities are compelled to redesign their work out of necessity and the need to ensure the continuation of vital care services to their residents. As a result, aged care service providers are increasingly exploring creative and alternative models of care and staffing in order to best meet the growing demand for high quality health care in light of the dwindling supply of registered nurses. This article reports on research undertaken to explore an innovative, non-traditional model of care developed at a 70 bed, residential aged care facility in regional north Queensland. Aspects of the model of care were developed organically over time by senior registered nurses at the facility in response to local need. All new roles were operating in the facility six months prior to this research being undertaken.

The innovation at this facility was driven by the need to consider alternative staffing configurations in order to optimise available registered nursing staff, provide 24 hour coverage for essential clinical services and to address the growing issue of registered nurses (RNs) working extended hours. This was deemed to be unsustainable in the longer term. In seeking a solution, it was determined that task allocation (particularly medication administration) was either directly or indirectly related to the excessive workload for RNs. While many facilities have delegated the task of medication administration to unregulated or personal care workers (PCWs), the approach undertaken at this facility was much broader and more comprehensive than merely the re-assignment of a clinical task to a lower level worker. Interestingly though, while individual component parts of the models were carefully developed over time to meet facility need, there was limited understanding of the complexity and integration of the ‘whole' as a model of care.

MODELS OF CARE: Definition
In exploring the literature, it became clear that the terminology and nomenclature applied to various models and frameworks that seek to describe or explain elements of nursing staffing and work organisation within any given health care context was diverse. Terms used include: workplace practice model; workforce staffing model; staffing model; nursing staff mix model; and model of care / care model / nursing care delivery system (Kimball, Joynt, Cherner & O'Neil, 2007; Wolf & Greenhouse, 2007; DoHA, 2005; McGillis-Hall, 2003; McGillis-Hall & Doran, 2003). The terms ‘models of care' and ‘staffing models' are often used interchangeably and are rarely clearly defined within the literature, while ‘workplace practice'; ‘staffing models' and ‘models of care' are very closely related and enmeshed with each other. Although there are multiple terms used to describe the organisation and roles of nursing staff, the most common of these is ‘models of care'. In light of the literature, the term ‘model of care' was used in this research and defined as a schematic representation used to organise and explain the delivery of care within a health care setting (Wolf & Greenhouse, 2007). A model of care identifies the members of the nursing and care team, their roles, responsibilities, accountabilities and decision-making authority. While not all of the models of care presented in the literature are represented schematically, which, by definition, is what a model is, they do present a common element in that they outline and organise the roles and practice of nursing and care personnel.

MODELS OF CARE: Literature Review
A number of traditional and non-traditional models of care have been identified within the literature. In brief, there are 5 main traditional models of care: 1. Functional Nursing; 2. Team Nursing; 3. Total Patient Care; 4. Primary Nursing; and 5. Case Management (Crisp & Taylor, 2005; Tiedeman & Lookinland, 2004). These are generally well defined within the literature and are widely understood within the nursing profession. While there are many differences in the focus, staffing and decision making and accountability structures within each of these models, there are some similarities from a research perspective. Primarily, the research evaluation of all these models in relation to quality of care, patient and staff satisfaction and economic factors is, by and large, inconclusive and contradictory (Tiedeman & Lookinland, 2004). Importantly, no clear and definitive data supports one approach over the others in all circumstances. This is partly due to variation in the application of these models as a result of the unique nature of the care environments and specific contextual factors. It is also partly due to the fact that registered nurses form an important conduit between policies, models and practice (Venturato, Kellett, & Windsor, 2007), thus the efficacy of any model of care, traditional or non-traditional, depends in large part on the understanding and subsequent application by registered nurses in the practice arena. These contextual factors apply to both traditional models, as well as non-traditional or alternative models of care.

In their review of non-traditional models of care, Lookinland, Tiedeman and Crosson (2005) identified 3 alternative categories:
1) clinical (partnered and non-partnered);
2) non-clinical; and
3) integrated models.
Partnered clinical models are those where an unregulated care worker is partnered with a registered nurse and the two work as a team providing care for their assigned patients. Both work the same shifts, with the RN delegating tasks to the assistant (often referred to as a patient care technician, nursing assistant or nurse extender). The role of the carer in these models is diverse and ranges from the highly technical to assistive, personal care tasks. The registered nurse remains accountable for all care. Non-partnered clinical models are those where the assistive staff provides direct patient care under the supervision and delegation of a number of registered nurses. No partnership exists between the RN and the care worker. In Lookinland et al's (2005) review, non-partnered nurse extenders tended to be based in acute care settings and included nursing and medical students, licensed practical nurses (equivalent to an EN), patient care technicians, and medication administration personnel. This model is considered similar to a traditional functional model in that tasks are assigned according to role. Non-clinical models involve the use of unregulated care workers in the provision of support rather than direct patient care (Lookinland et al, 2005). Roles include dietary aide, personal assistant, unit hostess, concierge, and service and supply staff. Integrated models use a combination of clinical and non-clinical models in that support staff may be involved in both direct care and indirect support activities.

Non-traditional models may also include skill mix models (McGillis-Hall, 2003). These models are generated from studies that seek to measure staffing numbers as an indicator and measure of quality care (Castle & Engberg, 2007; Räikkönen, Perälä & Kahanpää, 2007; Mueller, Arling, et al, 2006; Zhang, et al 2006; Harrington, 2005a; 2005b; Harrington, 2004; Mueller & Karon, 2004; Schnelle et al, 2004; Harrington, O'Meara, Collier, Schnelle, 2003; Harrington, Zimmerman, et al, 2000; & Harrington, et al, 2000). Skill mix models are based on numbers and proportions of regulated and unregulated staff rather than roles, structure and working relationships. This research tends to be political in nature and has been used in many states in the USA to lobby for, or raise, minimum staffing ratios, through establishing an association between staffing levels and a range of quality indicators.

Lookinland et al (2005) note that non-traditional models of care share a common focus on the integration and deployment of unregulated care staff and the reshaping of nursing work to accommodate a broader skill mix and decrease in the availability of registered nurses. The majority of these non-traditional models have been generated from within the acute care sector, however, and thus reflect staffing and skill mix considerations within this context. It is worthwhile noting that these models are often considered non-traditional because they deal with a different skill mix, that is, the addition of unregulated care workers, rather than because they represent an alternative way of conceptualising staffing and care provision.

Very few studies have been conducted to evaluate these models and those that have are often inconclusive as to their effectiveness in relation to cost and quality due to the diversity in the settings and contexts (Lookinland et al, 2005). Those studies that have evaluated models of care have focused on specific outcomes, such as staff or patient satisfaction, cost, or specific quality indicators such as infection rates or length of stay. In general though, Wolf and Greenhouse (2007: 384) highlight three observations from Tiedeman and Lookinland (2004) and Lookinland et al's (2005) review of the research literature:
(1) RNs have a positive impact on patient outcomes; (2) unlicensed assistive personnel can potentially be used effectively; and (3) outcomes are improved when care is coordinated over time, and accountability is assigned.

It is evident, therefore, that the literature on staffing and workforce issues reflects the diversity of settings and contextual factors. The aim of this research was to explore an existing, non-traditional model of care with an innovative staffing configuration within a residential aged care context. This exploration encompasses key elements of both traditional and non-traditional models of care, including consideration of decision making and accountability, structure (hierarchical or flat), the focus of care (person, relationship or task) and the relationships and roles within each model. In particular, the research was guided by the following research questions:

1. What is the model of care in use at this facility?

2. What influence has the implementation of a non-traditional model of care had in the work experiences of nursing and care staff in a residential aged care setting?

RESEARCH APPROACH

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