Differentiated nursing practice: assessing the state-of-the-science

Nursing Economics, Sept-Oct, 1997 by Constance M. Baker, Geneva M. Lamm, Alison R. Winter, Virginia B. Robbeloth, Cheryl A. Ransom, Franklin Conly, Kristen C. Carpenter, Lauri E. McCoy

Nurse managers are being challenged to make changes in the organization of nursing work to ensure quality, cost-effective nursing care. Despite minimal evaluation research, management innovations are being implemented throughout the health care delivery continuum (McCloskey et al., 1994). In this article, the authors present an integrative review of the evaluation research on differentiated nursing practice. First, the background and conceptualization of differentiated nursing practice are traced; second, details of the literature search and the findings are described; and third, the state-of-the-science is examined and an agenda for future research is suggested.

The Concept of Differentiated Nursing Practice

Differentiated nursing practice is a phrase used to describe the sorting of roles, functions, and work of registered nurses according to some identified criteria, commonly education, clinical experience, and competence (Boston, 1990). As a philosophy, differentiated nursing practice focuses on the division of labor required to meet client needs, the value of complementary educational preparation and clinical experiences, the need for collaboration to maximize effectiveness, and compensation based on academic preparation and performance. As a method, differentiated nursing practice has been operationalized as a system designed to provide distinct levels of nursing practice based on educational preparation and defined competencies (Primary, 1987). Thus, differentiated nursing practice is reflected in RN position descriptions based on educational preparation, competencies required by the patient population and setting, or professional experiences reflected in the career ladder. While differentiation provides health care organizations with needed expertise and skills in an uncertain environment, it also creates the need for integration to avoid fragmentation. This paradox of dividing the work yet integrating the efforts exists in all major industries affected by rapid technologic change (Lawrence & Lorsch, 1967).

Nursing has been differentiating roles for decades, but only during the past 15 years has the concept of differentiated nursing practice become visible. The competency model has been developed from at least two perspectives. In 1983 a New Jersey State Nurses Association task force developed a competency model based on the eight American Nurses Association's Standards of Nursing Practice, the client population and health care delivery setting, and the desired client outcomes (Wolahan, 1991). Although not the original intent, a competency model is reflected in Benner's five levels of practice: novice, advanced beginner, competent, proficient, and expert (Benner, 1984). Both of these approaches coincide with the professional career ladder notion designed to distinguish levels of practice and comparable financial rewards.

The education model is reflected in clinical position descriptions for graduates of ASN, BSN, and MSN programs. The pioneering project to develop competency-based education and position descriptions was sponsored by the Midwest Alliance in Nursing (MAIN) and funded by the Kellogg Foundation (Primary, 1987). This model is shown in Figure 1 and depicts three basic components of nursing: provision of care, communication, and management. Provision of care includes the necessary technical skills, communication includes the necessary interpersonal skills, and management of care includes leadership skills. Patient teaching is reflected when the provision of care sphere overlaps with the communication sphere. Delegation of care is reflected when the provision of care sphere overlaps with the management of care sphere. Coordination with other disciplines is reflected when the communication sphere overlaps with the management of care sphere.

[Figure 1 ILLUSTRATION OMITTED]

The three basic components of nursing have been operationalized by specifying nursing competencies according to educational preparation, which are placed in concentric circles to reflect the complexity of decision making in the nursing process. Further, it is assumed that the complexity of decision making and accountability increases in relation to client needs, orientation to time, and the setting in which care is delivered (Koerner, 1992). Newman (1990) has expanded this model to the graduate level and proposes a trilevel model of professional nursing practice based on differentiated roles for graduate, baccalaureate, and associate degree levels of education.

The rationale for differentiated nursing practice includes the potential for (a) optimal nursing care when the patient's needs are matched with the nurse's competencies, (b) effective and efficient use of scarce nursing resources, (c) equitable compensation based on education, expertise, and productivity, (d) increased career satisfaction among nurses encouraged to apply nursing knowledge, (e) greater loyalty to employer, and (f) enhanced prestige of nursing profession by integrating the community of nurses to deliver the full range of nursing services (McClure, 1991).