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

Briefly, the qualitative studies of differentiated nursing practice have been conducted in sites across the health care delivery continuum.

Instrumentation studies. A three-step process was used to develop a valid instrument to measure the three roles of Newman's trilevel model of professional nursing practice (Allender, Egan, & Newman, 1995). First, items were generated that were believed to reflect educational distinctions among the practice components of time and place orientations, client assignments, nursing observation and communication, and nursing interventions. Second, a pilot study was conducted with 12 nurses in a 300-bed hospital to establish clarity of the items. After some modifications, a two-prong third step was implemented, establishing content validity by testing the tool with another group of nurse clinicians and inviting two experts to compare written job descriptions with the items in the model. Detailed analysis of the process provides evidence that the nursing practice inventory (NPI) does measure differentiated nursing practice according to the Newman trilevel model.

The differentiated pay structure model determines a nurse's salary based on education, position, and expertise, adjusting the base salary for part-time employment, shift differentials, and bonuses to reward longevity (Cleland, Forsey, & DeGroot, 1993; Forsey, Cleland, & Miller, 1993). The model's applicability was tested with computer simulations and nursing data from two urban hospitals. Considerable data are presented to support the conclusions that the model can be phased in over a multi-year period, reduces institutional costs in salary compensation, and creates savings for salary based on education, position, and expertise. The model should be implemented in selected hospitals to assess the impact on nurses' behavior in relation to work patterns, career development, educational achievement, and nurse recruitment.

Tools to measure the quality of nursing care were reported from South Dakota and Illinois. A chart audit tool was developed to measure the quality of nursing care delivered in differentiated nursing practice and to instruct nurses about role expectations of case managers and case associates (Stenvig & Karpiuk, 1991). The initial 38 items in the tool were developed from competency statements for differentiated nursing roles and specific parameters of nursing care. While JCAHO was complimentary on the comprehensiveness of the tool, Community Health Accreditation Program (CHAP) required an additional six items, and five items were added to address risk management activities. Anecdotal evidence was provided to reflect the tool's usefulness in the hospital and ambulatory settings.

Measures of quality practice outcomes have been designed to measure differences between certified and noncertified neonatal nurses (Woods & Dvorak, 1991). The items were developed from concept papers of experts, survey of the literature, and one author's previous instrument. Background information and pilot project description support the utility of these measures.