E V I D E N C E S Y N T H E S I SModels of care in nursing.docx

E V I D E N C E S Y N T H E S I S
Models of care in nursing: a systematic reviewjbr_287 324..337
Ritin Fernandez RN MN (Critical Care) PhD,1,2 Maree Johnson
RN BAppSci MAppSci PhD,3,4
Duong Thuy Tran BMed (Vietnam) MIPH (USyd)5 and
Charmaine Miranda BPsycholgy6
1School of Nursing, Midwifery and Indigenous Health,
University of Wollongong, Wollongong, 2Centre for Research
in Nursing and
Health, St George Hospital, Kogarah, 3Centre for Applied
Nursing Research, Sydney South West Area Health Service,
4School of Nursing
and Midwifery, University of Western Sydney, Sydney, 5School
of Medicine, University of Western Sydney, Sydney, and
6Centre for Positive
Psychology and Education, School of Education, University of
Western Sydney, Sydney, New South Wales, Australia
Abstract
Objective This review investigated the effect of the various
models of nursing care delivery using the diverse levels
of nurses on patient and nursing outcomes.
Methods All published studies that investigated patient and
nursing outcomes were considered. Studies were
included if the nursing delivery models only included nurses
with varying skill levels. A literature search was
performed using the following databases: Medline (1985–2011),
CINAHL (1985–2011), EMBASE (1985 to current)
and the Cochrane Controlled Studies Register (Issue 3, 2011 of

Cochrane Library). In addition, the reference lists of
relevant studies and conference proceedings were also
scrutinised. Two reviewers independently assessed the
eligibility of the studies for inclusion in the review, the
methodological quality and extracted details of eligible studies.
Data were analysed using the RevMan software (Nordic
Cochrane Centre, Copenhagen, Denmark).
Results Fourteen studies were included in this review. The
results reveal that implementation of the team nursing
model of care resulted in significantly decreased incidence of
medication errors and adverse intravenous outcomes,
as well as lower pain scores among patients; however, there was
no effect of this model of care on the incidence of
falls. Wards that used a hybrid model demonstrated significant
improvement in quality of patient care, but no
difference in incidence of pressure areas or infection rates.
There were no significant differences in nursing outcomes
relating to role clarity, job satisfaction and nurse absenteeism
rates between any of the models of care.
Conclusions Based on the available evidence, a predominance
of team nursing within the comparisons is
suggestive of its popularity. Patient outcomes, nurse
satisfaction, absenteeism and role clarity/confusion did not
differ
across model comparisons. Little benefit was found within
primary nursing comparisons and the cost effectiveness
of team nursing over other models remains debatable.
Nonetheless, team nursing does present a better model for
inexperienced staff to develop, a key aspect in units where skill
mix or experience is diverse.
Key words: evidence-based practice, nursing, systematic
review.

Background
Various models for the delivery of nursing care such as
patient allocation, primary nursing and team nursing have
been implemented over the past few decades. These models
performed successfully in the workforce that mainly con-
sisted of registered nurses (RNs). However, over the past 10
years, the healthcare environment in Australia and globally
has undergone significant changes mainly due to shortages
of RNs and budget constraint.1 As a result, a major restruc-
ture of the nursing workforce has been undertaken2 includ-
ing filling RN positions with enrolled nurses (ENs), assistants
in nursing and unlicensed carers.3
This study sought to provide evidence of the effectiveness
of the varying models of care used in nursing, in particular,
team nursing (group of nurses caring for a large group of
patients for one shift) and patient allocation (one nurse
caring for a small number of patients for one shift). This
review will inform health service policy on when and how to
apply differing nursing models of care within practice.
Correspondence: Professor Ritin Fernandez, St George Hospital,
Kogarah, NSW 2217, Australia. Email: [email protected]
sesiahs.health.nsw.gov.au
bs_bs_banner
doi:10.1111/j.1744-1609.2012.00287.x Int J Evid Based Healthc
2012; 10: 324–337
© 2012 The Authors
International Journal of Evidence-Based Healthcare © 2012 The
Joanna Briggs Institute

In Australia, the inclusion of the differing levels of nurses
into the workforce has led to redefining the roles of RNs and
ENs in order to maximise the resources during the shortage.
For example, RNs have been given roles such as clinical
supervision and ENs are permitted to administer medica-
tions under the supervision of RNs. In some areas, ENs have
extended roles including wound care.4
Several adaptations and combinations of the traditional
models of patient care delivery have arisen in order to
accommodate the changing roles of nurses and the various
levels of nursing skill mix.5–8 These include team-oriented
models such as partners in care9,10 shared care nursing,8,11
modular nursing and partners in practice.12,13 Evaluations of
the various models of care delivery have demonstrated that
a RN-predominant skill mix is associated with better patient
health outcomes and lower mortality, improved quality of
care and reduction in medication errors and wound infec-
tions,14,15 which can be explained by RN’s ability to earlier
detect patient deterioration and intervene timely.16 Other
studies have found improvements in staff satisfaction,
recruitment and retention of staff and reduction in sick leave,
improved team spirit and a cleaner ward environment.17
Patient allocation models have also been implemented
with the varying skill mix and in one study8 there was no
difference in job satisfaction between a team-oriented model
and patient allocation model. Communication between all
members of nursing and interdisciplinary teams is believed
to be a key element for the success of any care delivery
models.18 In a study11 that compared a team-oriented and
patient allocation model of care, there were no significant
differences in communication at the 6-month follow up.

One of the disadvantages of the patient allocation model in
the current workforce is little capacity for supervising or
teaching inexperienced new staff and the possibility of junior
RNs and ENs being required to care for patients beyond their
skills and experience.17
A recent report from the New South Wales Health follow-
ing an inquiry into nursing services recommended the use of
a team model for nursing care delivery.19 However, the deci-
sion to change to a different model of care should be
informed by existing evidence to support or refute the effi-
cacy of the model. Although reviews have been previously
undertaken evaluating the various models of care, these
reviews have combined nursing care delivery models com-
prising of all RNs (e.g., team nursing with all RNs and patient
allocation with all RNs), as well as the various levels of nurse.
In contemporary nursing practice, wards staffed with all RNs
are fast becoming nonexistent.1 Therefore, the aim of this
study is to undertake a systematic review of the literature to
investigate the effect of the various models of nursing care
delivery using the diverse levels of nurses on patient and
nursing outcomes.
Methods
Inclusion/exclusion criteria
This review included randomised and non-randomised con-
trolled studies which compared different models of nursing
care involving nurses with varying skill mix. Reports pub-
lished from the year 2000 and in the English language only
were considered in this review. Studies that involved patients
aged 18 years and over and nurses who worked in hospital
settings were included. Studies undertaken in community
settings and those involved midwifery practices were
excluded. The focus of this review was on acute inpatient

settings, and midwifery practice and community nursing
represent unique contexts, warranting a discipline-specific
systematic review. Studies that compared any models of
nursing care delivery including team nursing, primary
nursing, functional nursing and case management models
were included. Studies that had all RN staffing were
excluded unless they were compared with a mixed skill
model. In the current health environment, having an all RN
staffing in the hospital setting is highly unlikely1; therefore,
these studies were excluded to reflect the current staffing
skill mix. Patient-, nurse- and organisation-related outcomes
were evaluated. Patient-related outcomes of interest were
the following: (i) incidence of errors and adverse events
including complaints, failure to rescue, falls, pressure sores,
morbidity and mortality; (ii) length of hospital stay and
readmission; (iii) quality of patient care; and (iv) patient
satisfaction. The nursing outcomes of interest were the fol-
lowing: (i) inter-professional communication, role clarity,
professional development and support from senior staff;
(ii) job satisfaction; (iii) staff attrition rate; and (iv) nursing
documentation. Cost effectiveness was assessed as an
organisational outcome. These outcomes were selected as
the evidence14,15 demonstrates that nursing skill mix can
have an impact on the outcomes listed.
Search strategy
With the assistance of a qualified health librarian, the follow-
ing databases were searched: Medline (1985–2011),
CINAHL (1985–2011), EMBASE (1985 to current) and the
Cochrane Controlled Studies Register (Issue 3, 2011 of
Cochrane Library). The search terms used were nursing care
delivery systems, nursing models of care, personnel staffing
and scheduling, nurse–patient ratio and nursing service. A
detailed description of the search strategy used can be
obtained from the authors. Additionally, the reference lists
and bibliographies of all possible studies and reviews were

searched for further references. Relevant conference pro-
ceedings, key word searching of the World Wide Web and
grey literature were looked at using the above-mentioned
keywords to complement the search strategies. The follow-
ing sites for grey literature were searched: OpenGrey, Vir-
ginia Henderson International Nursing Library and the New
York Academy of Medicine.
Study selection, assessment of methodological
quality and data extraction
All abstracts identified from the literature search were
screened by two reviewers. There was 100% concordance
between the two reviewers. The relevant full text articles/
reports were obtained and assessed for eligibility against the
inclusion/exclusion criteria independently by two reviewers.
Models of care in nursing 325
© 2012 The Authors
Studies that met the inclusion criteria were selected for
potential inclusion. Studies that were reported in more
than one publication were included only once. Any disagree-
ments were resolved by discussion with a third reviewer.
The methodological quality of the eligible studies was
assessed independently by two reviewers using the Joanna
Briggs quality assessment tool for experimental and non-
experimental studies (Table 1). There was 100% concor-
dance between the two reviewers. Methodological quality
assessment was according to the following criteria: (i)
detailed description of inclusion and exclusion criteria used
to obtain the sample; (ii) evidence of allocation concealment

at randomisation; (iii) the validity of methods of outcome
assessment; (iv) description of withdrawals and dropouts;
and (v) the potential for bias in outcome assessment. The
minimum score obtainable for methodological quality using
these tools was 10 and maximum of 30. For this review, the
mean quality score minus one SD was adopted as the thresh-
old for defining studies of adequate quality.20 Studies that
obtained a quality score equal to or above this threshold
were included in the analysis, while those that did not meet
the threshold quality score were excluded. Data extraction
was undertaken by one reviewer using a data extraction tool
that was developed for the review. All data extracted were
checked by a second reviewer.
Data analysis
Data were analysed using the RevMan 5.1 software (Nordic
Cochrane Centre, Copenhagen, Denmark). Odds ratios and
95% confidence intervals were calculated for dichotomous
outcomes. Analysis of continuous outcomes involved calcu-
lation of the mean and SD to derive standardised mean
differences and 95% confidence intervals. As the studies
were heterogeneous in terms of the various models of care
and outcomes assessed, meta-analysis could not be under-
taken. Therefore, the results are summarised as a narrative
report with forest plots presented where relevant.
Results
Approximately 3000 studies were identified from the search
strategy. The majority were rejected based on the inclusion
and exclusion criteria. Sixteen studies were critically
appraised for methodological quality. Based on the criteria for
quality assessment, the calculated mean quality score was
22.9 (SD � 3.0; range 20–28); therefore, the quality thresh-
old was considered to be 20. Fourteen studies involving a
total of 2000 participants were included in the final analysis
based on the quality threshold (Fig. 1). The majority of the

studies included were comparative studies with concurrent
controls. Due to the nature of the interventions, none of the
participants or the patients were blinded to the treatment
groups.
The majority (n = 5) of the studies included in the review
were conducted in the Unites States; the remaining were
conducted in Norway, Australia, the UK, Netherlands, Ireland,
Sweden, Hong Kong, Italy and Canada. The models of care
implemented included team nursing, primary nursing,
patient allocation and hybrid models of care delivery
(Table 2).
The number of participants in the studies ranged from
2026 to 1137 nurses29 (Table 3). The mean age of the nurses
ranged from 35.5 to 60.1 year. In the three studies that
reported the gender of the nurses, the majority (87–94%)
were female nurses. Studies were carried out in both public
and private hospitals. The various models of care reported
were implemented in general hospital wards,8,25,26,28–30
medical surgical wards,12,24,27,31 orthopaedic, psychiatric
ward,7 intensive care unit22 and acute care23,27 (Table 3).
Effect of the model of care on patient outcomes
Errors and adverse events
Medication errors. Two studies23,28 investigated the effects
of team models of care on medication incidents and adverse
intravenous outcomes.23 The number of medication inci-
dents at the 6-month follow up was higher than baseline but
Table 1 Critical appraisal checklist
JBI critical appraisal checklist for experimental studies
Reviewer _____ Date _____
Author _____ Year _____ Record Number _____

Yes No Unclear
1. Was the assignment to treatment groups truly random? � � �
2. Were participants blinded to treatment allocation? � � �
3. Was allocation to treatment groups concealed from the
allocator? � � �
4. Were the outcomes of people who withdrew described and
included in the analysis? � � �
5. Were those assessing outcomes blind to the treatment
allocation? � � �
6. Were the control and treatment groups comparable at entry?
� � �
7. Were groups treated identically other than for the named
interventions? � � �
8. Were outcomes measured in the same way for all groups? �
� �
9. Were outcomes measured in a reliable way? � � �
10. Was appropriate statistical analysis used? � � �
Overall appraisal: Include � Exclude � Seek further info. �
Comments (Including reasons for exclusion)
_____________________________________________________
___________________________
_____________________________________________________
___________________________
_____________________________________________________
___________________________
326 R Fernandez et al.
© 2012 The Authors

declined to below baseline values at the 12-month follow up
in the team model.23 Similarly, the incidence of medication
errors was significantly lower at the 18-month follow up
when compared with baseline values following the introduc-
tion of the team model of care.28
The percentage of adverse intravenous outcomes
decreased at 6- and 12-month follow up in the team
model.23 There was no statistically significant difference in
the incidence of adverse intravenous between the mixed skill
team model and all RN model at the 6- (P = 0.35) and
12-month (P = 0.19) follow up23 (Fig. 2).
Falls. Two studies23,28 investigated the incidence of patient
falls in team models of care delivery. In the first trial,23 the fall
rates per patient day in the mixed skill team model was
significantly higher (P = 0.006) at the 12-month follow up
compared with the all RN model (0.002).23 In the second
trial28 that investigated the impact of team nursing, there
was no significant difference in the rates of falls at 6-, 9- and
12-month follow up (P > 0.05).28
Pain. One trial24 assessed pain scores among patients who
received team nursing and patient care delivery models. Pain
scores at the 24- to 48-h follow up were significantly lower
among general patients in the team nursing model24 com-
pared with total patient care (P = 0.005) (Fig. 3).
Other adverse events. Two studies investigated the effect
of a hybrid model (combination of patient allocation and
team nursing) of nursing care delivery. In the first trial,27 no
Table 2 Description of the various models of care
Author Model of care

Boumans et al.21 Patient oriented care: a form of primary
nursing with all RNs. Two RNs were responsible for a specific
group of
about six patients for 8 h a day (one work shift), 5 days a week
Differentiated practice: a form of team nursing. Involves RNs,
ENs and nurse aides. Nurses with varying skill levels
Gill et al.22 Team nursing: nurses allocated to groups of
patients for variable but usually considerable lengths of time
Non-team nursing: patient allocation model
Tourangeau
et al.23
The partnership nursing care delivery model: partnership
between two RNs and one personal support assistant on
day and evening shifts to complete all work
All RN staffing model
Barkell et al.24 Team nursing model: PCAs assisting RNs. Role
of RN was to direct and oversee patient care, delegate basic
patient
care activities
Total patient care: RN was responsible for giving total care to
patient
Malkin25 Primary nursing: RN was responsible for giving total
care to patient
Non-primary nursing RN and EN responsible for giving total
care to patient
McPhail et al.26 Primary nursing: RN assumes direct
responsibility for the care of a given number of patients and was
paired with

associate primary nurse and registered nursing assistants
Team nursing: no description
Morris et al.7 Nurse-directed care model: (hybrid) combined
components of primary nursing and team nursing models
Pre-implementation: custodial model (not stated)
Fowler et al.27 Collaborative ‘shared care’ model: (hybrid)
contained elements of patient allocation and team nursing
models of
care
Pre-implementation model: not stated
Seago28 Patient focused care: team approach to care delivery
Primary nursing: no description given
Tran et al.8 Shared care in nursing model: team work
comprising of RNs, ENs and assistants
Patient allocation: one RN is responsible for total care of a
number of patients
Sjetne et al.29 Team leader dominated: a team of nurses is
responsible for a small group of patients
Primary nurse dominated: a single nurse is responsible for all
care to a strictly limited number of patients during
their hospital stay
Hybrid (combination of team leader and primary care)
Glandon et al.12 Team nursing: team of RNs, LPNs and aides
provide care under the supervision of the team leader
Primary nursing: care of a specific patient is under the
continuous guidance of one nurse from admission to
discharge

Modular model: a group of staff to care for a group of patients
Total patient care: nurses are responsible for total care of a
patient but only for the hours that specific nurse is
present
Kangas et al.30 Team nursing: RNs, LPNs and AINs form a
team to provide care for a group of patients. Tasks are divided
according
to skill level
Case management: nurses assigned specific patients to follow
and monitor throughout their hospital stay
Primary nursing: RNs cared for a consistent group of patients
over a time as acuity and nurse scheduling allowed
MacLeod and
Sella31
Primary nursing: care coordinated by primary nurse
Pre-implementation model: team nursing
AINs, assistants in nursing; ENs, enrolled nurses; LPN, licensed
practical nurse; PCA, patient care assistant; RNs, registered
nurses.
Models of care in nursing 327
© 2012 The Authors
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te
ca
re
co
m
m
u
n
it
y

h
o
sp
it
al
Fo
llo
w
u
p
:
6
an
d
1
2
m
o
n
th
s
T
h
e
p

ar
tn
er
sh
ip
n
u
rs
in
g
ca
re
d
el
iv
er
y
m
o
d
el
:
p
ar

tn
er
sh
ip
b
et
w
ee
n
tw
o
R
N
s
an
d
o
n
e
p
er
so
n
al

su
p
p
o
rt
as
si
st
an
t
o
n
d
ay
an
d
ev
en
in
g
sh
ift
s
to
co

m
p
le
te
al
l
w
o
rk
A
ll
R
N
st
af
fin
g
m
o
d
el
6
-m
o

n
th
fo
llo
w
u
p
In
th
e
p
ar
tn
er
sh
ip
m
o
d
el
w
ar
d
s

th
er
e
w
as
•
Si
g
n
ifi
ca
n
t
in
cr
ea
se
in
p
at
ie
n
t
kn

o
w
le
d
g
e
re
la
ti
n
g
to
in
tr
av
en
o
u
s
th
er
ap
y
•
D

ec
re
as
e
in
p
at
ie
n
t
fa
lls
•
In
cr
ea
se
in
m
ed
ic
at
io
n

in
ci
d
en
ts
•
D
ec
re
as
e
in
ti
m
e
sp
en
t
b
y
R
N
s
in

as
si
st
in
g
p
at
ie
n
ts
w
it
h
ac
ti
vi
ti
es
o
f
d
ai
ly
liv

in
g
N
o
d
iff
er
en
ce
b
et
w
ee
n
th
e
tw
o
m
o
d
el
s
re

la
ti
n
g
to
•
A
d
ve
rs
e
in
tr
av
en
o
u
s
th
er
ap
y
o
u
tc

o
m
es
•
Le
ve
l
o
f
n
u
rs
e
d
is
sa
ti
sf
ac
ti
o
n
•
P
at

ie
n
t
ca
re
co
st
s
1
2
-m
o
n
th
fo
llo
w
u
p
In
th
e
p
ar

tn
er
sh
ip
m
o
d
el
w
ar
d
s
th
er
e
w
as
•
In
cr
ea
se
in
p

at
ie
n
t
fa
lls
•
D
ec
re
as
e
in
m
ed
ic
at
io
n
in
ci
d
en
ts

A
ll
o
th
er
o
u
tc
o
m
es
si
m
ila
r
to
6
-m
o
n
th
fo
llo
w
u

p
B
ar
ke
ll
et
a
l.2
4
U
SA
P
re
-
an
d
p
o
st
-s
tu
d
y
2

6
9
6
p
at
ie
n
ts
fr
o
m
su
rg
ic
al
w
ar
d
1
3
9
p
at
ie
n

ts
h
o
sp
it
al
w
id
e
Fo
llo
w
u
p
:
6
m
o
n
th
s
Te
am
n

u
rs
in
g
m
o
d
el
:
P
C
A
s
as
si
st
in
g
R
N
s.
R
o
le
o
f

R
N
w
as
to
d
ir
ec
t
an
d
o
ve
rs
ee
p
at
ie
n
t
ca
re
,
d

el
eg
at
e
b
as
ic
p
at
ie
n
t
ca
re
ac
ti
vi
ti
es
To
ta
l
p
at

ie
n
t
ca
re
:
R
N
w
as
re
sp
o
n
si
b
le
fo
r
g
iv
in
g
to

ta
l
ca
re
to
p
at
ie
n
t
N
o
si
g
n
ifi
ca
n
t
d
iff
er
en
ce

b
et
w
ee
n
th
e
tw
o
m
o
d
el
s
re
la
ti
n
g
to
•
St
af
fin

g
co
st
s
•
Le
n
g
th
o
f
h
o
sp
it
al
st
ay
•
P
at
ie
n
t
sa

ti
sf
ac
ti
o
n
sc
o
re
In
th
e
te
am
n
u
rs
in
g
m
o
d
el
o
n

p
o
st
-o
p
D
ay
s
1
an
d
2
th
er
e
w
as
a
•
Si
g
n
ifi
ca
n

t
in
cr
ea
se
in
th
e
n
u
m
b
er
o
f
d
o
cu
m
en
te
d
p
ai

n
sc
o
re
s
(P
=
0
.0
0
6
)
•
Si
g
n
ifi
ca
n
t
d
ec
re
as
e

in
p
at
ie
n
t’
s
p
ai
n
sc
o
re
(P
=
0
.0
1
7
)
M
al
ki
n

2
5
U
K
Su
rv
ey
2
4
3
2
p
ri
m
ar
y
n
u
rs
es
p
ai
re
d

w
it
h
n
o
n
-p
ri
m
ar
y
n
u
rs
es
w
o
rk
in
g
in
th
e
O

xf
o
rd
sh
ir
e
H
ea
lt
h
A
u
th
o
ri
ty
in
g
en
er
al
fie
ld
s
Fo

llo
w
u
p
:
si
n
g
le
p
o
in
t
su
rv
ey
P
ri
m
ar
y
n
u
rs

in
g
:
R
N
w
as
re
sp
o
n
si
b
le
fo
r
g
iv
in
g
to
ta
l
ca

re
to
p
at
ie
n
t
N
o
n
-p
ri
m
ar
y
n
u
rs
in
g
:
R
N
an
d

EN
re
sp
o
n
si
b
le
fo
r
g
iv
in
g
to
ta
l
ca
re
to
p
at
ie
n

t
N
o
si
g
n
ifi
ca
n
t
d
iff
er
en
ce
b
et
w
ee
n
th
e
tw
o

m
o
d
el
s
re
la
ti
n
g
to
•
In
tr
in
si
c
jo
b
sa
ti
sf
ac
ti

o
n
•
Ex
tr
in
si
c
jo
b
sa
ti
sf
ac
ti
o
n
•
In
te
n
ti
o
n
s

to
st
ay
in
n
u
rs
in
g
•
P
er
ce
p
ti
o
n
o
f
n
u
rs
in
g
as

C
an
ad
a
R
C
T
2
8
2
0
n
u
rs
es
an
d
1
0
8
p
at
ie
n
ts

fr
o
m
a
m
ed
ic
al
/s
u
rg
ic
al
u
n
it
in
a
te
rt
ia
ry
ca
re

te
ac
h
in
g
h
o
sp
it
al
Fo
llo
w
u
p
:
8
m
o
n
th
s
P
ri
m

ar
y
n
u
rs
in
g
:
R
N
as
su
m
es
d
ir
ec
t
re
sp
o
n
si
b

ili
ty
fo
r
th
e
ca
re
o
f
a
g
iv
en
n
u
m
b
er
o
f
p
at
ie
n

ts
an
d
w
as
p
ai
re
d
w
it
h
as
so
ci
at
e
p
ri
m
ar
y
n
u

rs
e
an
d
re
g
is
te
re
d
n
u
rs
in
g
as
si
st
an
ts
Te
am
n
u

rs
in
g
:
n
o
d
es
cr
ip
ti
o
n
N
o
si
g
n
ifi
ca
n
t
d
iff

er
en
ce
b
et
w
ee
n
th
e
tw
o
m
o
d
el
s
re
la
ti
n
g
to
•

In
te
rp
er
so
n
al
re
la
ti
o
n
sh
ip
•
P
er
so
n
al
g
ro
w
th
•

R
o
le
cl
ar
it
y
an
d
co
n
tr
o
l
•
Q
u
al
it
y
o
f
p
at

ie
n
t
ca
re
•
P
at
ie
n
t
sa
ti
sf
ac
ti
o
n
M
o
rr
is
et
a
l.7

U
SA
P
re
-
an
d
p
o
st
-s
tu
d
y
2
3
5
3
n
u
rs
in
g
an

d
p
ar
ap
ro
fe
ss
io
n
al
st
af
f
fr
o
m
a
st
at
e
p
sy
ch
ia

tr
ic
h
o
sp
it
al
Fo
llo
w
u
p
:
9
m
o
n
th
s
N
u
rs
e-
d
ir
ec

te
d
ca
re
m
o
d
el
:
(h
yb
ri
d
)
co
m
b
in
ed
co
m
p
o
n

en
ts
o
f
p
ri
m
ar
y
n
u
rs
in
g
an
d
te
am
n
u
rs
in
g
m
o

d
el
s
P
re
-i
m
p
le
m
en
ta
ti
o
n
:
cu
st
o
d
ia
l
m
o
d

el
(n
o
t
st
at
ed
)
Fo
llo
w
in
g
im
p
le
m
en
ta
ti
o
n
o
f

th
e
h
yb
ri
d
m
o
d
el
•
9
0
%
im
p
ro
ve
m
en
t
in
cl
in

ic
al
p
ra
ct
ic
es
an
d
cl
ie
n
t
liv
in
g
en
vi
ro
n
m
en
t
•

R
ed
u
ct
io
n
in
in
ci
d
en
ts
o
f
se
cl
u
si
o
n
an
d
re
st

ra
in
t
Fo
w
le
r
et
a
l.2
7
A
u
st
ra
lia
P
re
-
an
d
p
o
st

-s
tu
d
y
2
5
Tw
o
ac
u
te
ca
re
w
ar
d
s
at
a
te
ac
h
in
g
h

o
sp
it
al
Fo
llo
w
u
p
:
1
ye
ar
C
o
lla
b
o
ra
ti
ve
‘s
h
ar
ed

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