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

The American Organization of Nurse Executives (AONE), the American Association of Colleges of Nursing (AACN), and the National Organization for Associate Degree Nursing have endorsed differentiated nursing practice as a strategy to maximize the utilization of scarce nursing resources (1995).

Method of Literature Review

Four approaches were used to identify relevant nursing literature. A computerized search of Cumulative Index of Nursing and Allied Health Literature (CINAHL), MED-LINE, HEALTH INFOTRACK, and Health Planning and Administration was conducted using the following keywords: differentiated practice, nursing delivery systems, and nursing assignment. The Indiana University computerized library catalog was searched using keywords: nursing and differentiated practice, nursing and delivery models. References in research articles were pursued. Recent nursing management books were manually searched. Informal consultation yielded governmental publications. Nearly 100 articles on differentiated nursing practice were identified, 21 data-based articles were critiqued. Finally, ten related articles were reviewed to provide a summary of the empirical evidence to inform managerial decisions about differentiated nursing practice and suggest needed research.

The Stetler/Marram model was used to evaluate the applicability of research findings (Stetler, 1994). Emphasis was placed on key dimensions of the nursing practice model (McCloskey et al., 1994). Findings are presented according to the type of study: quantitative, qualitative, or instrumentation.

Review of the Literature

Despite the extensiveness of the literature search, only nine articles reported quantitative research on differentiated nursing practice, seven articles presented case studies with anecdotal evidence, and five articles reported information on developing tools for differentiated nursing practice. Some projects have been presented in several reports, only the data-based articles are included in this article.

Among the nine articles presenting quantitative data, six presented projects in multi-institutions and four articles are from the same two projects. The first and largest project was implemented in the state of South Dakota, four of the sites are represented in this review with two quantitative articles, two qualitative articles, and one article on instrumentation. New York City's "nursing initiative program" involved nine units in four hospitals. One of the Arizona studies involved nine units in three hospitals. The comparison study of Michigan nurses involved 14 units in four hospitals. Both Colorado and Utah have projects involving multi-institutions. A single hospital was the site of the projects in Arizona, Connecticut, Florida, Massachusetts, and New Hampshire. Community-based projects are reported from Minnesota, Pennsylvania, and South Dakota. The instrumentation studies are reported from Arizona, California, Illinois, Minnesota, and South Dakota.

Quantitative studies. Hospital units were the setting for all eight quantitative studies, whether to pilot a potential hospital-wide change, serve as a demonstration site, or provide nurse subjects for comparisons. The education-based Utah project is included here although quantitative data have not yet been published.