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

Researchers implementing a DGPP model developed two tools to assess the degree of progress in implementing the model and the strength of the model on professional practice variables (Milton, Verran, Gerber, & Fleury, 1995). Using Rogers' diffusion of innovation, a scale was developed to monitor the degree to which DGPP was implemented on the hospital unit. Since implementing change sometimes occurs in stages with various components progressing at different rates, the second scale was developed to assess the degree to which people view the changes as an integrated whole. Establishing interrater reliability is described in sufficient detail that these scales should be useful in monitoring other efforts to implement differentiated nursing practice and measure outcome variables.

Briefly, several tools to measure various aspects of differentiated nursing practice have been published and are applicable across the health care delivery continuum.

State-of-the-Science Discussion

The state of the science is presented in relation to the conceptualization of differentiated nursing practice, organizational contexts, implementation costs, stakeholder outcomes, and methodologic issues.

Conceptualization. A major issue in research on differentiated nursing practice is establishing construct clarity and specifying its boundaries. Differentiated nursing practice is a complex multidimensional phenomenon based on structuring nursing roles and functions according to education, experience, and competence. Following the initial project in South Dakota with the ASN and BSN positions, subsequent projects have added the full range of nursing workforce: unlicensed nursing assistants, practical nurses, diploma-prepared nurses, and masters-prepared nurses. Little attention has been given to the nursing research that shows education affects work performance and educational differences influence specific types of nursing performance (Johnson, 1988; Marz, 1989; McCloskey & McBain, 1988).

Moving beyond the criteria for differentiation, operationalizing differentiated nursing practice involves the major processes of delegation, teaching, and leadership. Delegation and the method of patient care assignment are key aspects of implementing differentiated nursing practice. Case management and primary nursing are the methods of patient care assignment mentioned most often; the potential relationship of method and outcomes must be considered. While staff development has been described in various projects, very little attention has been given to patient teaching. As the differentiation increases in the staff mix, so too does the need for coordination of work efforts and leadership. Projects addressed the need for coordination and integration through values consensus (Cronenwett et al., 1991), shared governance (Milton et al., 1992), and integrated care (Koerner & Karpiuk, 1994). Several projects experienced "slippage" in relation to sustaining the differentiated practice model, roles changed (Malloch et al., 1990), especially during different tours of duty (Harkness et al., 1992) and in response to caregiver's absenteeism (Milton et al., 1991).