D I S C U S S I O N P A P E RNursing Services Delivery The.docx

D I S C U S S I O N P A P E R
Nursing Services Delivery Theory: an open system approach
Raquel M. Meyer & Linda L. O’Brien-Pallas
Accepted for publication 30 July 2010
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Correspondence to R.M. Meyer:
e-mail: [email protected]
Raquel M. Meyer PhD RN
Nursing Early Career Researcher
Ontario Ministry of Health & Long-Term
Care, and
Assistant Professor (CLTA)
Lawrence Bloomberg Faculty of Nursing,
University of Toronto, Ontario, Canada

Linda L. O’Brien-Pallas PhD RN FCAHS
Professor & CHSRF/CIHR Chair in
Nursing Human Resources
Lawrence Bloomberg Faculty of Nursing,
University of Toronto, Ontario, Canada
M E Y E R R . M . & O ’ B R I E N - P A L L A S L . L . ( 2 0 1
0 )M E Y E R R . M . & O ’ B R I E N - P A L L A S L . L . ( 2
0 1 0 ) Nursing services delivery theory:
an open system approach. Journal of Advanced Nursing 66(12),
2828–2838.
doi: 10.1111/j.1365-2648.2010.05449.x
Abstract
Aim. This paper is a discussion of the derivation of the Nursing
Services Delivery
Theory from the application of open system theory to large-
scale organizations.
Background. The underlying mechanisms by which staffing
indicators influence
outcomes remain under-theorized and unmeasured, resulting in a
‘black box’ that
masks the nature and organization of nursing work. Theory
linking nursing work,

staffing, work environments, and outcomes in different settings
is urgently needed to
inform management decisions about the allocation of nurse
staffing resources in
organizations.
Data sources. A search of CINAHL and Business Source
Premier for the years
1980–2008 was conducted using the following terms: theory,
models, organization,
organizational structure, management, administration, nursing
units, and nursing.
Seminal works were included.
Discussion. The healthcare organization is conceptualized as an
open system
characterized by energy transformation, a dynamic steady state,
negative entropy,
event cycles, negative feedback, differentiation, integration and
coordination, and
equifinality. The Nursing Services Delivery Theory proposes
that input, throughput,
and output factors interact dynamically to influence the global
work demands
placed on nursing work groups at the point of care in production
subsystems.

Implications for nursing. The Nursing Services Delivery Theory
can be applied to
varied settings, cultures, and countries and supports the study of
multi-level phe-
nomena and cross-level effects.
Conclusion. The Nursing Services Delivery Theory gives a
relational structure for
reconciling disparate streams of research related to nursing
work, staffing, and work
environments. The theory can guide future research and the
management of nursing
services in large-scale healthcare organizations.
Key words: nursing management, Nursing Services Delivery
Theory, open system
approach, organization structure, quality of care, staffing, work
organization
Introduction
In many countries, the sustainability and quality of nursing
services are threatened by global shortages of healthcare
professionals (International Council of Nurses 2006). As one
component of a multifaceted response to this crisis, policy

and decision-makers have prioritized the nursing practice
environment and organizational performance as key areas for
2828 � 2010 Blackwell Publishing Ltd
J A N JOURNAL OF ADVANCED NURSING
intervention (International Council of Nurses 2006). Nursing
services are generally contracted through an employment
relationship. To recruit, retain, and deploy scarce nursing
human resources effectively and to produce quality and cost-
effective care, the associations between organizational struc-
tures, human resource management policies and the goals,
resources, context, and outcomes of nurses’ work need to be
understood. A challenge in nursing health services research
has been the need for a unifying theory to conceptualize and
examine the delivery of nursing services (Edwardson 2007).
In the conceptual model for nursing and health policy,
Russell and Fawcett (2005) identified four levels of focus:
(i) nursing practice processes; (ii) administrative practices

for nursing service (or healthcare) delivery subsystems;
(iii) healthcare system administrative practices; and (iv)
world health administrative practices. The Nursing Services
Delivery Theory (NSDT) addresses the second level of
phenomena in this model by examining the effectiveness
and efficiency of administrative practices for nursing service
delivery subsystems. Using the strategy of theory derivation,
the NSDT gives a theoretical understanding of the nature of
an organization, situates the work of nurses in the organi-
zational context, and integrates the design and organization
of nursing work. In this study, we present a description of the
derivation of the NSDT from the application of Open System
Theory to large-scale organizations and the structural and
conceptual elements of the NSDT. Examples from the
empirical literature are used to illustrate the relational
structure the NSDT describes among nursing work, work
environment, and staffing variables. Further implications of
the theory are discussed.

Background
Nursing health services research is characterized by a
growing need for a coherent theoretical framework that
combines clinical, organizational, financial, and outcome
variables from a nursing perspective (Edwardson 2007).
Nurse staffing studies often apply traditional nurse staffing
indicators to give crude estimates of the amount of nursing
resources available for care. However, by virtue of their
simplicity, nurse staffing indicators also de-contextualize
care. Conceptually, hours per patient day (HPPD) assume a
standard time per occupied bed, whereas nurse–patient ratios
are based on average nurse capacity (O’Brien-Pallas et al.
2005). Workload measurement systems quantify patients’
requirements for nursing care as the sum of the times of the
tasks required or as the amount of time required relative to
standard patients (Thibault et al. 1990). In the community,
numbers of visits reflect standard times allotted per home
visit. These types of nurse staffing indicators inadequately

consider factors known to influence variability in nursing
work, namely the characteristics of care recipients and
nursing teams, and factors related to the care delivery
environment (O’Brien-Pallas et al. 1997).
Although staffing research examining large administrative
data sets in the United States of America (USA), Canada, and
the United Kingdom has identified associations between key
nurse staffing indicators and patient outcomes at the
organizational level (Lankshear et al. 2005), these types of
secondary analyses do not measure the actual work
performed by nurses (Clarke 2006). Thus, the underlying
mechanisms by which staffing indicators influence outcomes
remain under-theorized and unmeasured, resulting in a
‘black box’ that masks the nature and organization of
nursing work. Although large database studies allow for
comparisons across organizations, evidence on which to re-
organize and improve nursing services to varied clinical
populations at the point of care is lacking (Clarke 2006).

Specific theory and evidence linking staffing practices and
outcomes in different settings are urgently needed to inform
management decisions about the allocation of nurse staffing
resources in organizations.
A review of funded nursing health services research in the
USA identified that conceptual frameworks were often used
in isolation by researchers (Edwardson 2007). Donabedian’s
(1980) Healthcare Organization and Delivery Model is one
of the most frequently used frameworks to examine nursing
performance (Hall 2004, Edwardson 2007). Conceptual
frameworks of nursing care based on Donabedian’s (1980)
formulation for the assessment of care quality typically
organize patient, nurse, work, work environment, and
outcome variables according to structure, process, and
outcome (e.g. Irvine et al. 1998, Cho 2001). However,
because Donabedian (1980) was focused on an approach
for assessing the quality of medical care, rather than on
system design and organization, the fundamental questions of

‘What is an organization?’ and ‘What is nursing work?’
remain unanswered. Rationales for including variables in a
structure–process–outcome framework have tended to rely
on empirical findings, rather than a theoretical understanding
of the nature of an organization or the delivery of nursing
services. In addition, because linear relationships are fre-
quently assumed between structure, process, and outcome
variables, the dynamic interactions between variables are
often neglected (Mitchell et al. 1998).
Building on a rich tradition of systems thinking in clinical
(Holden 2005) and nursing management, the NSDT
addresses many of these challenges to nurse staffing and
nursing work research. In particular, Jelinek (1967) described
JAN: DISCUSSION PAPER Nursing Services Delivery Theory
� 2010 Blackwell Publishing Ltd 2829
a Patient Care System Model composed of personnel types
and physical facilities as inputs; organizational and environ-

mental factors as throughput; and patient care, patient
satisfaction, and personnel satisfaction as outputs. Subse-
quently, the interrelationships among nursing complexity,
medical complexity, nurse characteristics, environmental
complexity, and outcomes were tested in a systems model
in community and hospital settings to investigate the factors
that cause patients or clients with very similar medical
conditions to have different nurse resource requirements
(O’Brien-Pallas et al. 1997, 2001, 2002, 2004, Meyer et al.
2009). In these models, inputs consisted of the characteristics
of patients or clients, nurses, and the system and system
behaviours; throughput involved the nursing care delivery
subsystem, where nursing interventions are performed and its
environmental complexity; and outputs involved outcomes
for patients or clients, nurses, and the system. Mark et al.
(1996) also applied structural contingency theory, a subset of
Open System Theory, to the evaluation of nursing system
outcomes. Key variables included environment (e.g. organi-

zational size, skill mix), technology (e.g. stability of patient
acuity, diversity of patient conditions), structure (e.g. degree
of centralization), and effectiveness (e.g. patient and admin-
istrative outcomes). The basic premise was that to perform
effectively and to produce quality outcomes, an organization
must structure its nursing units to complement the environ-
ment and technology.
The NSDT complements and extends the scope of
previous systems models in nursing by theorizing the nature
of an organization, locating the work of nursing at the work
group level in an organizational suprasystem, and explicat-
ing the division and coordination of nursing work. By
viewing the healthcare organization through the lens of
objectivism, the work of nurses is assumed to exist as an
objective, external reality with identifiable and measurable
characteristics.
The theory derivation was guided by these questions:
What is the nature of an organization? How do healthcare

organizations produce nursing services? How do manage-
ment structures contribute to the delivery of nursing
services? According to Walker and Avant (2005), theory
derivation is an iterative and creative process that involves:
(i) becoming very familiar with the level of theory develop-
ment in the field and evaluating existing theories; (ii) reading
widely both in and outside the field of study to make creative
associations between distinct fields of study; (iii) choosing a
parent theory for the derivation; (iv) identifying which
content and structural elements of the parent theory will be
used; and (v) recasting these elements for the phenomenon of
interest.
Data sources
Building on our pre-existing knowledge, literature from the
nursing, healthcare, and management fields was examined. A
search of CINAHL and Business Source Premier was
conducted using combinations of the following terms: theory,
models, organization, organizational structure, management,

administration, nursing units, and nursing. The search was
limited to English language, peer-reviewed publications or
books published between 1980 and 2008. Seminal works
were also included. Documents with a major focus on theory
related to work performance and management in organiza-
tions were reviewed.
Discussion
Katz and Kahn’s (1978) The Social Psychology of Organi-
zations, based on Open System Theory, was selected as the
parent theory because it addressed the questions guiding the
derivation in a comprehensive manner and facilitated new
insights and connections about research in the areas of
nursing work, staffing, and work environments. Selected
structural and conceptual elements of the parent theory were
redefined. Specifically, the open system characteristics of
organizations and the five functional subsystem types, which
are the fundamental defining characteristic of social systems
(Katz & Kahn 1978), were recast in the NSDT with an

emphasis on the dynamics and mechanisms of production
subsystems.
Open System Theory
The theoretical foundation of the NSDT is Open System
Theory as applied to large-scale organizations by Katz and
Kahn (1978). In their view, an organization constitutes an
energic input–output system. An organization depends on its
supporting environment for continued inputs to ensure its
sustainability and processes these inputs through the recur-
ring and patterned activities and interactions of individuals to
yield outputs. An organization is therefore essentially a social
system. As such, an organization and its subsystems strive to
achieve a dynamic steady state whereby regularities in energy
flow preserve the character of the system and disturbances
prompt system adaptation (Katz & Kahn 1978). To survive,
an organization needs to counteract entropy, which is an
inevitable process of disorder and dissolution caused by loss
of inputs or by inability to transform energies. An open

system must acquire negentropy (i.e. negative entropy),
usually through some form of storage capacity, to ensure its
continued existence (Katz & Kahn 1978). For organizations,
R.M. Meyer and L.L. O’Brien-Pallas
negentropy can involve renewing inputs, storing energy,
creating slack resources, or maximizing imported energy
relative to exported energy (Galbraith 1974, Katz & Kahn
1978). Organizations can also counteract entropy by adapt-
ing system functioning in response to informational signals
and feedback from the environment. Characteristics of open
systems and their application to large-scale organizations and
to the NSDT are presented in Table 1.
Open System Theory recognizes the hierarchical nature of
entities, whereby each level of the organization comprises a
‘subsystem’ of interrelated parts. In large-scale organizations,
the transformation of energy (i.e. throughput) occurs in

production subsystems that divide the labour to accomplish
tasks (Katz & Kahn 1978). The function of the production
subsystem is to transform energy to meet task requirements
and to optimize task accomplishment via technical profi-
ciency (Katz & Kahn 1978). The underpinning mechanism is
the division of labour that determines the structure and work
flow in the production subsystem. Subdividing the work
creates breaks in work flow. Organizations address this
challenge by integrating work processes across roles and
subunits using coordination devices (Katz & Kahn 1978). As
an organization differentiates, additional integration and
coordination are required to unify system functioning (Katz
& Kahn 1978). Thus, the size, complexity, and coordination
demands of an organization increase as its subsystems
multiply and specialize in function.
The production subsystems interact dynamically with the
supportive, maintenance, and adaptive subsystems of the
broader organization (Figure 1). These subsystems import

people, materials, and energies through transactions at the
organizational boundaries; balance internal work structures
relative to human inputs by formalizing activities and
socializing and rewarding members; and deal with problems
of adjustment to external forces by recommending and
incorporating change (Katz & Kahn 1978). Overall organi-
zational functioning and adjustment to external demands are
coordinated and integrated by the management subsystem,
which crosscuts and directs all subsystems and negotiates
conflict across hierarchical levels (Katz & Kahn 1978). In
terms of functioning, the production, supportive, mainte-
nance, adaptive, and management subsystems do not operate
in isolation, but rather are interdependent and interact
dynamically as part of a greater, complex whole.
As an open system, the organization adapts its functioning
in response to negative feedback and external informational
signals through a series of iterative adjustments that allow the
system to evolve while maintaining its character (Katz &

Table 1 Open system concepts and their corollary in the Nursing
Services Delivery Theory
Concept Definition (Katz & Kahn 1978)
Application to large-scale
organization (Katz & Kahn
1978)
Application to the Nursing
Services Delivery Theory
Inputs The inflow of energy and
information from the external
environment renews the
system
Energic inputs may include
people, materials, or resources
from other organizations.
Informational inputs include
negative feedback or signals
about the external
environment

People – e.g. staff, care
recipients
Materials – e.g. supplies
Resources – e.g. funding
Information – e.g. labour
market conditions
Throughput Energies inside the system are
transformed by reorganizing
the inputs
Reorganization may entail
processing of materials,
generation of products, or
provision of services
Services – e.g. nursing
interventions
Output Product must be exported to
the external environment
Outputs may consist of

materials, products, or
services
Service outputs – e.g. patient
volumes
Systems as cycles
of events
The process of exchanging and
transforming energy must
renew the system thus
creating a repeated series of
activities
Renewal may be generated by
system output or by its own
activities
Outputs – e. g., revenues
Activities – e.g. accreditation
criteria achieved
Negative feedback Internal information about

system functioning is a
corrective device used to
adjust energy intake and
expenditure
Subsystem feedback about
operational functioning is
used to keep the organization
on target
Negative feedback – e.g.
organizational performance
indicators
Kahn 1978). Although Figure 1 is a simplified representation
of the organization as an open system, the phenomenon is
neither uni-dimensional nor static. Large-scale organizations
typically consist of multiple interacting subsystems (e.g.

multiple production subsystems by specialty, hierarchically
layered management subsystems). The principle of equifinality
states that an open system can achieve its end state from
various initial conditions and through differing trajectories
(Katz & Kahn 1978). This suggests that there is no single way
for an organization to be structured or to achieve positive
outcomes.
Nursing Services Delivery Theory
The NSDT applies Open System Theory to nursing work in
large-scale healthcare organizations (Figure 2). With respect
to system structure, the NSDT identifies that care is delivered
by nurses clustered in work groups that are nested in a
department or programme in the larger organization. Inpa-
tient units in a hospital or nursing teams in home healthcare
are examples of production subsystems. These work groups
transform energic inputs to deliver nursing services and to
yield outputs. Imported inputs consist of care recipients, staff,
material and fiscal resources and information, which are

subsequently transformed in a nursing production subsystem
through the work performed, its structure, and its internal
work conditions.
Distal outputs include clinical, human resource, and
organizational outcomes. These energic outputs give feed-
back and reactivate the system in a cyclical manner because
positive outcomes in each of these domains ensure that
members of the community continue to use the organization’s
services, staff are retained to give the services, and the
organization’s accreditation and funding are sustained. With
respect to nurse staffing, entropy may be counteracted in
several ways. Examples of negentropy include: (i) renewal of
inputs by retaining or hiring nurses; (ii) storing energy by
using buffer inventories of nursing capacity (e.g. float pools,
agency nursing); (iii) creation of slack resources by loosening
performance targets to reduce the number of exceptions
(e.g. longer lengths of stay), by increasing fiscal resources
(e.g. greater nursing HPPD), or by extending lead times (e.g.

richer staffing ratios); and (iv) more efficient use of imported
energy relative to exported energy by intensifying nursing
workload to increase volumes (e.g. lower staffing ratios).
In Open System Theory, each system and its subsystems
adapt to internal and external demands and feedback.
Demands external to the healthcare organization encompass
environmental factors (e.g. labour market, legislation, popu-
lation characteristics). Healthcare organizations continuously
Throughput
Organization suprasystem
Management subsystem
• Integration & coordination of
system functioning
Supportive subsystem
• Importation of inputs
Production subsystem
• Transformation of energy
Maintenance subsystem
• Formalization of activities & socialization
of members

Adaptive subsystem
• Monitoring & responses to external forces
• Change integration
Inputs Outputs
Products
Services
Materials
People
Energies
Figure 1 Simplified representation of the organization as an
open system based on Katz & Kahn (Meyer 2010, reproduced
with permission).
adapt system functioning in response to feedback and infor-
mational signals to counteract entropy. For example, aligning
organizational policies to meet performance targets set by
external agencies exemplifies the dynamic interaction between

the organization and its external environment.
At the point of care, each nursing production subsystem
also adapts to and interacts reciprocally with the other
organizational subsystems. The management, supportive,
maintenance, and adaptive subsystems coordinate and allo-
cate the inflow of energic inputs and establish the structures
necessary for the completion, evaluation, and renewal of
nursing work in production subsystems. Internal demands of
nursing production subsystems relate to the nature of the
work performed, structures arising from the division of
nursing labour, and the work conditions at the point of care.
Negative feedback includes organizational performance indi-
cators (e.g. longer than expected length of stay or time on
programme).
The dynamic interdependence among subsystems, the
organization, and the external environment is illustrated
using the example of emergency department overcrowding
and one of its proposed solutions, the introduction of nurse

practitioners. In response to pressures to reduce crowding
(i.e. external demand), subsystems would recommend and
implement the proposed solution (i.e. adaptive function); hire
the nurse practitioners (i.e. supportive function); formalize
policies to enable the work of nurse practitioners (i.e.
maintenance function); and integrate these changes across
subsystem, role, and hierarchical boundaries to ensure
stakeholder buy-in and to monitor performance (i.e. man-
agement function). The emergency department (i.e. nursing
production subsystem) would re-divide the labour to accom-
modate the new role and the work performed (i.e. internal
demands). By altering the staffing mix (i.e. inputs), service
capacity (i.e. throughput) is increased, leading to reduced
overcrowding and increased consumer satisfaction (i.e. orga-
nizational and clinical outcomes; e.g. Carter & Chochinov
2007). In turn, because nurse practitioners typically engage in
primary care and health promotion, unnecessary readmis-
sions to the emergency department could be offset in the

future (i.e. feedback cycle).
By considering the various inputs and throughputs that
influence nursing service delivery and outputs, the NSDT
proposes that nursing work in a given production subsystem
is not performed in isolation; rather, nursing work in
production subsystems is dynamically interdependent with
the other subsystems and the organization suprasystem that
interact with the external environment. There is no single
Throughput
Organization suprasystem
Includes management, supportive, maintenance,
adaptive & production subsystems
• Type, size, location, structure, ideology
Nursing
production subsystem
Nature of the work
• Technology
• Input quantity & uncertainty
Structure
• Size
• Role design
• Staffing practices

• Nursing care delivery model
• Coordination mechanisms
Work conditions
• Work environment
• Power
Care recipient characteristics
• Demographics
• Resources
• Health
• Medical condition
• Nursing condition
• Self-mangement
Nurse characteristics
• Demographics
• Profession
• Health
Other energic sources
• Materials
• Fiscal resources
• Information

OuputsInputs
Clinical outcomes
• Clinical status
• Functional status
• Valuation
• Safety
Human resource outcomes
• Health
• Safety
• Profession
Organizational outcomes
• Quality
• Efficiency
• Resource utilization
Figure 2 The Nursing Services Delivery Theory.
way for an organization, or for nursing production subsys-

tems, to deliver nursing services effectively. The NSDT
emphasizes that a confluence of factors determines the global
work demands in the nursing production subsystem.
Components of the Nursing Services Delivery Theory
As shown in Figure 2, the delivery of nursing services in
production subsystems occurs inside the environment struc-
tured by the organization suprasystem, and is dependent on
the inflow of inputs, which include care recipients, nurses,
materials, and other energies.
Characteristics of the organizational suprasystem include
organizational type, size, location, structure, and ideology.
Type of organization can vary by healthcare sector (e.g.
acute, community or long-term care), academic affiliation, or
by funding source. Location may refer to geography (e.g.
rural, urban) or dispersion (e.g. multi-site organization,
catchment areas). Depending on the purpose of the inquiry,
organizational size can be measured as the quantity of
personnel, physical capacity, volume of inputs or outputs, or

discretionary resources of an organization (Kimberly 1976).
Organizational structure results from trade-offs between the
differentiation of work by function (e.g. nursing, pharmacy)
and the integration of work processes by programme (e.g.
cardiology, trauma; Charnes & Tewksbury 1993). This gives
rise to a continuum of functional, matrix, and programme
organizational forms (Charnes & Tewksbury 1993). Ideology
refers to the common norms and values held by the majority
of organizational members about expected member behav-
iours and the appropriateness of organizational activities and
functions (Katz & Kahn 1978).
Care recipient characteristics include demographics, health
status, resources, medical condition, and nursing condition.
Examples of demographic variables are age, gender, lan-
guage, and ethnicity. Health status includes the physiological
and psychosocial health states of the person. Resources
available to care recipients can be considered in terms of
material support (e.g. healthcare coverage) and social support

(e.g. informal caregivers). Medical condition encompasses the
number and types of medical diagnoses and co-morbidities
and severity. Nursing condition refers to the healthcare needs
of recipients that generate the demand for nursing services in
terms of complexity (e.g. number and types of nursing
diagnoses) or intensity (e.g. workload). Self-care management
involves the pre-existing knowledge, health behaviours, and
symptom management of care recipients and their informal
caregivers about the underlying health conditions.
Nurse characteristics consist of demographic, professional,
and health factors. Demographics include age and gender.
Profession reflects occupational factors such as licensure,
education, clinical expertise, experience, and employment
status. Health entails the physiological and psychosocial
health states of the nurse.
Other energic sources include materials, fiscal resources,
and information. Materials consist of equipment and
supplies. Fiscal resources refer to the budget allocated to a

production subsystem. Information can include, but is not
limited to, organizational trends and policies, new technol-
ogies, and feedback that the production subsystem imports
from other organizational subsystems.
Throughput consists of several factors. Nursing work is
performed in the production subsystem. Key factors influenc-
ing the delivery of nursing services in the production subsystem
entail the nature of the work, its structure, and its environ-
ment. Technology refers to the work performed by nurses.
Nursing work may be conceptualized as independent and
collaborative interventions that encompass ‘any treatment,
based upon clinical judgment and knowledge, which a nurse
performs to enhance patient/client outcomes’ (McCloskey &
Bulechek 2000, p. 3). In terms of the nursing work performed,
technology refers to task uncertainty (i.e. degree to which
cause and effect are analysable), instability (i.e. the degree to
which moment to moment changes in care recipient status
occur), and variability (i.e. diversity of number of different

components; Overton et al. 1977). The extent to which tasks
are interdependent (Thompson 1967) and time-constrained
(Adler 1995) is an additional dimension of work performance.
Temporal dimensions of nurses’ work (e.g. duration, tempo-
rality, timing, tempo) may also be considered (Jones 2001).
Uncertainty, instability, variability, interdependence, and
timing of nursing work and interventions are amenable to
measurement. Quantity and uncertainty of inputs also influ-
ence nursing work in the production subsystem. Input quantity
may be reflected by volumes of care recipient admissions,
visits, procedures, or patients; by number of staff or nursing
HPPD; or by fiscal resources. Input uncertainty is determined
by the number and probability of choices or alternatives in a
given situation (Argote 1982). With respect to care recipients,
uncertainty is reflected by diversity in the health conditions
and care needs of the population served and the number of
exceptional cases encountered. For example, patient flow to a
haemodialysis unit is more predictable in terms of admission

rates and patterns, service times, sequencing, and health
conditions, compared with an emergency department.
Uncertainty in staffing inputs is exemplified by, but not limited
to, nursing skill mix, team composition, the proportion of
full-time staff, and the use of overtime and agency staff to
meet demand. Uncertainty in material inputs entails changes
in the allocation of fiscal and material resources.
The structure of the nursing production subsystem arises
from the division and coordination of nursing work through
management subsystem decisions about size, role design,
staffing practices, nursing care delivery models, and coordi-
nation mechanisms. Size refers to the capacity to produce
services (e.g. numbers of beds or available home visits). Role
design assigns responsibility for particular tasks to distinct
job descriptions. Staffing practices refers to the ways in

which care activities and responsibilities are divided among
nurses at a micro-level based on care recipients (e.g. nurse–
patient ratios, workload scores), staff characteristics (e.g.
experience levels), or management practices (e.g. length and
scheduling of shifts). Nursing care delivery models (e.g.
team, primary or total care models) describe how nursing
work is divided and coordinated at the work group level.
Coordination entails mechanisms to standardize skills, work
processes (e.g. clinical pathways), outcomes, or communica-
tion methods (e.g. electronic health record; March & Simon
1958, Venkatraman 1994). Feedback is another coordina-
tion device that fosters the exchange of information in an
adaptive and reciprocal manner (Gittell 2002). Feedback can
occur through direct supervision, boundary spanning roles
(e.g. case managers), or teamwork (Gittell 2002). Work
conditions internal to the production subsystem encompass
the various physical, cognitive, psycho-social, and profes-
sional dimensions of the work environment that influence

professional practice (Kristensen 1999, Registered Nurses’
Association of Ontario 2008). In the systems approach,
power is typically conceptualized as a resource. Empowered
work environments are those in which all employees can
access opportunities to learn and grow and can obtain the
information, support, and resources necessary for the job
(Kanter 1977).
The outputs in NSDT reflect key outcomes of nurses’ work
and work environments. Clinical outcomes sensitive to
nursing care can be grouped along four dimensions (White
et al. 2005). Clinical status outcomes involve the control or
management of symptoms (White et al. 2005) and the
prevention of complications (Irvine et al. 1998). Functional
status outcomes encompass the physical and psychosocial
functioning and self-care abilities of the individual (White
et al. 2005). Valuation refers to care recipients’ perceptions
and appraisals of nursing care and care results (e.g. satisfac-
tion; White et al. 2005). Safety outcomes include adverse

events and complications (White et al. 2005). Human
resource outcomes are related to staff members’ physical
and mental well-being, safety (e.g. injuries, violence), and
profession (e.g. autonomous practice, work satisfaction).
System outcomes incorporate evaluations of service quality
(e.g. rates of adverse events), efficiency (e.g. target volumes,
length on service), and resource utilization (e.g. staffing
stability, costs).
Application
Examples from the empirical literature illustrate the rela-
tional structure of the NSDT using inputs, throughputs, and
outputs that are integral to nursing health services research.
In a first example, Doran et al. (2006) explored the relation-
ships between patient characteristics (i.e. inputs), nursing
interventions (i.e. throughput), and clinical outcomes (i.e.
outputs). Patient functional and cognitive status and depres-
sion (i.e. health), but not age (i.e. demographics), were
associated with the types of nursing interventions performed

(i.e. technology). Nursing interventions in turn partially
mediated the relationship between functional status at
baseline and at discharge, suggesting that other variables,
such as patients’ pre-existing health conditions and the work
of other healthcare professionals, may be also influencing
outcome achievement (Doran et al. 2006).
A second example illustrates the use of buffer inventories to
respond to unpredictable staffing needs. Float pool and agency
nurses (i.e. inputs) have the potential to lower organizational
costs (i.e. resource utilization), but may be detrimental to
clinical outcomes under certain conditions. In a study of an
intensive care unit, after controlling for the characteristics of
patients (e.g. demographics, medical condition), patients
receiving care from a higher ratio of pool and agency nurses
to permanently assigned nurses (i.e. input uncertainty) were at
significantly greater risk for blood stream infections (i.e.
clinical status; Robert et al. 2000). These authors surmised
that agency and float pool staff may receive less training with

respect to central venous catheter care and may be less familiar
with team functioning and unit practices.
A third example highlights the potential for inter-profes-
sional practice to improve care delivery. For example, in a
study of joint replacement surgery, workgroups with high
levels of teamwork were associated with improved clinical
and organizational outcomes (Gittell 2004). The work
performed was concurrent and iterative (i.e. interdependent),
involved multidisciplinary roles (i.e. variable), and was
delivered under declining lengths of stay (i.e. time con-
strained). The throughputs consisted of teamwork (i.e. coor-
dination mechanism), patient volumes (i.e. input quantity),
and a specialized patient population (i.e. low input uncer-
tainty). Outputs included patient satisfaction with care quality
(i.e. valuation) and length of stay (i.e. efficiency). After
controlling for patient demographics (i.e. patient characteris-
tics), volume enhanced the positive effects of specialization on
teamwork and on outcomes. Teamwork in turn mediated the

effect of specialization on improved outcomes, suggesting that
the benefits of specialization are in part achieved through high
levels of teamwork (Gittell 2004).
In a final example, nursing work environments remain a key
priority among healthcare employers, particularly for staff
recruitment and retention in the context of nursing shortages.
A study of new nurse graduates (i.e. inputs) revealed that those
who experienced greater employee-job fit (i.e. throughput)
were more likely to report improved human resource outcomes
(i.e. outputs; Cho et al. 2006). When nurses with less than two
and a half years experience (i.e. nurse characteristics) had
access to opportunity, information, support, and resources (i.e.
power), they were more likely to perceive greater fit in terms of
workload, control, rewards, community, fairness, and values
(i.e. work environment), and in turn they reported higher work

engagement and consequently less burnout and greater orga-
nizational commitment (i.e. nurse health and profession
outcomes). These examples highlight the capability of the
overarching framework and the conceptual underpinnings of
the NSDT to support theoretical connections among distinct
streams of nursing services research related to nursing work,
work environments, and staffing variables.
Implications for nursing
The NSDT explains the contributions of the organizational
suprasystem and its subsystems to the global work demands
placed on nurses in production subsystems. To avoid a black
box approach to investigating the work of nurses, the actual
work performed (e.g. technology) by nurses at the point of
care, and not merely the structures or work conditions,
should be measured. The NSDT also integrates the nested
nature of organizational phenomena, thereby encouraging
the study of multiple levels of phenomena and the examina-
tion of cross-level effects and interactions. Because the NSDT

offers an abstracted view of the phenomena and is broad in
scope, its components cannot be tested comprehensively or
directly in any single study.
Future research can be guided by this theory to examine
how variations in inputs, throughputs, and organizational
characteristics result in optimal outputs related to nursing
services delivery. Empirical indicators need to be chosen
carefully to reflect the concepts in the NSDT. The compo-
nents of the NSDT are interactive and dynamic, not static.
Depending on the specific hypotheses to be tested, the
empirical indicators used to represent NSDT concepts may
serve as independent or dependent variables to given equa-
tions in the analytical models (Jelinek 1967). As conceptu-
alized, the input, throughput, and output components of the
NSDT are likely to be relevant across countries, cultures, and
settings because of the open system premise. However, the
measurement of phenomena (i.e. selection of empirical
indicators) may be tailored to specific countries, cultures, or

settings. The fields of organizational design and organiza-
tional behaviour can assist in building hypotheses, assuming
that the principles of open systems are upheld, to examine
why and how variations in inputs, throughputs, and supra-
system characteristics result in optimal outputs across nursing
services delivery production subsystems.
The NSDT can also be used to manage the factors
influencing nursing services delivery in organizations. Accu-
What is already known about this topic
• Because the delivery of nursing services has typically
been investigated using hospital-level staffing indicators,
the underlying mechanisms by which nursing work
influences outcomes remain under-theorized and
unmeasured.
• Large-scale organizations can be conceptualized as open
systems composed of interacting subsystems that
selectively import and transform energic inputs from the
external environment to produce services and products.
What this paper adds

• The healthcare organization is conceptualized as an
open system characterized by energy transformation,
a dynamic steady state, negative entropy, event cycles,
negative feedback, differentiation, integration and
coordination, and equifinality.
• This theory situates the work of nursing in the
production subsystems of the organization and
explicates the division and coordination of nursing
work.
• The theory gives a relational structure that reconciles
how nursing work, staffing, and work environment
variables contribute to the global work demands placed
on nurses at the point of care.
Implications for practice and/or policy
• Future research can be guided by this theory to examine
how variations in inputs, throughputs, and
organizational characteristics result in optimal outputs
related to nursing services delivery.
• Managers can use this theory as an overarching
framework to manage the key components
conceptualized to influence the delivery of nursing

services at the point of care in organizations.
mulated and synthesized evidence is needed to explain the
conditions under which the delivery of nursing services in
large-scale healthcare organizations influences clinical,
human resource, and organizational outcomes.
Conclusion
Nursing health services research has often been criticized for
being atheoretical. Investigation of a wide variety of nurse
staffing and work environment indicators has contributed to
a fragmented understanding of nursing services delivery and
nurses’ work. By placing these studies in the relational
structure of the NSDT, a theoretical basis is given for
reconciling disparate streams of research. The NSDT can
facilitate the identification of unstudied gaps and the selection
of conceptually meaningful variables for future research. The

NSDT also offers managers new insights with which to
prioritize and evaluate concurrent organizational initiatives
directed at increasing nursing service efficiency, effectiveness,
and sustainability. The NSDT thus offers an overarching
theory for examining and managing the key concepts
theorized to influence the delivery of nursing services at the
point of care in large-scale healthcare organizations.
Funding
This work was supported by Doctoral Fellowships from the
Canadian Institutes of Health Research (No. 70487) and the
Nursing Health Services Research Unit.
Conflict of interest
No conflict of interest has been declared by the authors.
Author contributions
RMM and LLOBP were responsible for the study conception
and design. RMM performed the data collection and analysis
and drafted the manuscript. RMM and LLOBP made critical
revisions to the paper for important intellectual content.

LLOBP supervised the study.
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The Journal of Advanced Nursing (JAN) is an international,
peer-reviewed, scientific journal. JAN contributes to the
advancement of
evidence-based nursing, midwifery and health care by

disseminating high quality research and scholarship of
contemporary relevance
and with potential to advance knowledge for practice,
education, management or policy. JAN publishes research
reviews, original
research reports and methodological and theoretical papers.
For further information, please visit JAN on the Wiley Online
Library website: http://onlinelibrary.wiley.com
Reasons to publish your work in JAN:
• High-impact forum: the world’s most cited nursing journal and
with an Impact Factor of 1Æ518 – ranked 9th of 70 in the 2010
Thomson Reuters Journal Citation Report (Social Science –
Nursing). JAN has been in the top ten every year for a decade.
• Most read nursing journal in the world: over 3 million articles
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• Fast and easy online submission: online submission at
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PubMed).
Week 1 Main Post Clark Adrienne -6041
When I joined the Air Force in 1992, my initial goal was to
serve only four years that extended to 2o years with many great
rewarding experiences. The military culture is a unique
organization in its own ways such as its mission, vision,
strategic planning, and military community lifestyle. The
current organization primary mission is to Treat- Teach -Train.
That being said, its mission is based on deployment platforms
and a teaching hospital. The organization trains physicians in
graduate medical, educational programs which are integrated
with a local state university school of medicine. The
organization also has a stand-alone training program for nurses,
technicians, dental hygienists and other types of healthcare
providers just to name a few.
With the recent military personnel force reduction last year, the
organization is now considered to be the third largest regional
Air Force teaching hospital. Airmen from the medical center
provided patients with a full range of health nursing and
medical care services, ranging from newborns, laser eye surgery
to comprehensive cancer care and frequently provide deployed
medical support around the globe. Although there is no single
definition of organization culture, Bellot (2011) defines
organizational culture as of shared values and beliefs that
govern how people behave in groups. Also, the military’s
culture of an organization provides guidelines and boundaries

that help the staff to know and to perform their jobs correctly
for accountability. Besides, the culture of the military
organization is so deep-rooted in the behavior of the airmen that
there is cohesiveness of being mission ready. Whereas, when a
non-military member observed the military’s culture it is
perceived as being too firm and involved, and the organization
is very difficult to follow through. Thus, the culture can be
thought of as 'personality' driven by the influence of the
organization (Bellot, 2011).
Furthermore, the culture and climate of the organization can be
constant or fluid depends on the seasonal change in new
leadership every two to four years related to relocating to
another military base installation or transitioning to civilian.
Whereas, the new inbound leadership style can have a positive
or negative effect on upper and lower management and staff
within the organization (Marqui & Huston, 2012). For example,
when the organization receives a new hospital medical group or
base wing commander. The staff will have an opportunity to
complete a culture and climate assessment survey that measured
and compared the attitudes and perceptions of hospital staff
toward a broad range of culture-related issues. As a result, the
surveys are provided an insight the need for change in our
military culture due to internal and external influences. NURS
6053-10
Overall, the role of the nurse leader is to lead by example and to
support the mission, vision, and values of the Air Force core
values: integrity, service before self, and excellence in all we
do. The goal is to pull the team to together to be in align with
the organization’s values’ (Nelson & Gardent, 2011).
Also, when I think of the roles and responsibilities of a nurse
leader, who plays a significant role in advocating for nursing
standard of care and patient-nurse relations via “interpersonal
collaboration” comes to mind (ANA, 2015). Also, nurse leaders
need to communicate clearly and concisely and to structure their
ideals strategically in line with the organization’s mission and

goals (ANA, 2015). Together with nurse frontline managers
and clinical leaders, and nurse informatics leaders help set the
organization’s direction and goals. In addition, these teams
strive for consistent practices and accountability across an
organization
References
American Nurses Association, (2015). Code of ethics.
Retrieved
from http://www.nursingworld.org/Mobile/Code-of-Ethics
Bellot, J. (2011). Defining and assessing organizational
culture. Nursing Forum, 46(1),
29–37. Retrieved from the Walden Library databases.
Nelson, W. A., & Gardent, P. B. (2011). Organizational values
statements. Healthcare
Executive, 26(2), 56–59. Retrieved from the Walden Library
databases.
Marquis, B. L., & Huston, C. J. (2012). Leadership roles and
management functions in
nursing: Theory and application (Laureate Education, Inc.,
custom ed.).
Philadelphia, PA: Lippincott, Williams & Wilkins.

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