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

Finally, precision in conceptualizing differentiated nursing practice is needed to distinguish it from team nursing (Harkness et al., 1992) and interdisciplinary practice (Hutchens, 1994).

Context. Several environmental forces have influenced the development of differentiated nursing practice including the nursing shortage, cost and quality initiatives, and shifting philosophies regarding health care delivery. Some potential explanations for the nature of the national distribution of projects implementing differentiated nursing practice include priorities of professional organizations, availability of qualified nurse scholars and administrators, and investment of external monies.

The organizational context within which differentiated nursing practice is implemented include both the external and task environments and the general organizational conditions. The hyperturbulent health care environment and the continuing professionalization of nursing have facilitated the implementation of a variety of nursing care delivery models (Koerner, 1992). Contextual factors within the task environment include sociocultural, political, economic, and technological dimensions (Miller, 1994).

Published project reports reflect involvement of the full continuum of health care organizations: hospitals, clinics, home care, hospices, and neighborhood centers. Inadequate attention has been given to describing the ownership and nature of the organization before the project began, other innovations being implemented simultaneously, and such key nursing variables as mission and philosophy, administrative structure and leadership style, and history of caregiver satisfaction, absenteeism, and turnover.

Information is needed on the overall purpose and time frame of these projects within their organizational context; some were aimed at organizational change, others were searching for methods of cost efficiencies, still others were focused on reducing nurse turnover. Very few project reports included sufficient demographic information on caregivers' education, experience, age, length of employment, types of patients served, and key organizational characteristics.

Implementation costs. Differentiated practice is assumed to provide health care organizations with the most effective and efficient use of scarce resources needed to contend with a rapidly changing health care environment; but, integration of these efforts is necessary to ensure goal achievement (Lawrence & Lorsch, 1967). Integration mechanisms include standardization of work and skills and feedback mechanisms to exchange information among autonomous caregivers (Alfred, Arford, & Michael, 1995).

Beyond work standardization based on education and position descriptions, little attention has been given to the organizational investment required to implement differentiated nursing practice. Some authors mention a consultant (Malloch et al., 1990) and others speak to staff development (Harkness et al., 1992; Koerner & Karpiuk, 1994), but little evidence of implementation costs has been found. Researchers report investments required to prepare nursing workforce for these processes (Cronenwett et al., 1991; Harkness et al., 1992) and the relationship of these employer expectations to nurses' strain (Marz, 1989), but the relationship of these variables to project outcomes needs examination. No studies were found that compared implementation costs of preparing current staff for differentiated nursing practice with appointing new staff according to education and competencies.