Friday, September 27, 2002

This presentation is part of : Nursing Role Effectiveness Model: Conceptualizing to Theory Testing

Development of the Nursing Role Effectiveness Model

Diane Irvine Doran, RN, PhD, associate professor, Faculty of Nursing, Faculty of Nursing, University of Toronto, Toronto, ON, Canada

Objectives: Health care professionals work within a system of interdependent roles and collaborate with each other for the common goal of quality health care. A comprehensive conceptualization of the interdependency of health care professionals' roles and functions is essential for devising strategies for quality improvement and for examining the contribution of professional groups to outcome achievement. A conceptual model was developed to guide the examination of the contribution of nursing within the health care system. In the model, the achievement of specific outcomes is related to the roles nurses assume in health care. The objectives of this paper are to present the conceptual model, and discuss its application to outcomes research and nursing quality improvement.

Variables: The Nursing Role Effectiveness model was based on the structure-process-outcome model of quality care (Irvine, Sidani, McGillis Hall, 1998a). The structure component consists of nurse, patient, and nursing unit variables that influence the processes and outcomes of health care. Nurse structural variables include nurses' work experience, formal and continuing education, as well as psychological variables such as self-efficacy. Patient structural variables comprise the patient characteristics that influence decisions about nursing care and/or patients' capacity for good outcomes. These include variables such as patient age, education, health status, and health expectations. Unit structural variables comprise the factors within the practice setting that influence nurses' ability to engage in effective role performance. These include variables such as nurse staffing, leadership, and structures to support role clarity and professional autonomy.

Nurses' independent role comprises the activities of patient assessment, decision-making, nursing intervention, and follow-up. Examples of independent role functions include diagnosing activities, (e.g. physical examination), planning activities (prescribing treatments), and care-related activities (e.g., patient education) (Sidani, et al., 2000). Nurses' interdependent role comprises the role functions and responsibilities which nurses share with other members of the health care team. It includes the activities and functions in which nurses engage that promote continuity and the coordination of patient care. Nurses' medical-care related role comprises the clinical judgments and activities associated with the implementation of medical orders and medical treatments. The outcome component of the model includes the patients' health status, the patients' perceived health benefit from nursing care, and the direct and indirect costs associated with nursing care.

Methods: Inductive methods were used to build a conceptual understanding of nurses' practice roles that included review of organizations' job descriptions and performance appraisal tools and clinical diaries to document role activities (Doran et al., 2000; Sidani et al., 2000). Deductive methods were used to review the empirical literature in order to identify structural variables that influence role performance and outcomes that can be linked to nurses' roles in health care (Irvine et al., 1998a; Sidani & Irvine, 1999). Two empirical studies provided support for the propositions in the Nursing Role Effectiveness Model and have led to a reformulation of some of the propositions. For example, Doran, McGillis Hall, Sidani, et al. (in press) found nurse staffing and the nurse-patient ratio affected the quality of nurse communication, which is an interdependent role function. Communication in turn, affected patients' functional independence at the time of hospital discharge. Doran, Sidani, Keatings, and Doidge (in press) found a relationship between nurses' interdependent and independent role performance and patients' therapeutic self-care ability at hospital discharge. Nurses' role performance variables were inter-related and were influenced by the educational preparation of nurses, work experience, and perceived role tension.

Conclusions: The utility of conceptual models is in their ability to simplify reality in a way that leads to valid predictions and understanding of relationships among complex phenomena. The Nursing Role Effectiveness model provides a way to conceptualize nurses' contribution to health care and has proven useful for understanding the influence of unit and nurse structural variables on nursing practice and patient outcome achievement.

Implications: The inter-dependencies among the role performance variables are recognized in the reformulation of the Nursing Role Effectiveness Model. The conceptual model has guided the development of a program of research aimed at identifying and measuring nursing-sensitive outcomes (Irvine Doran et al., in press), has been used as a framework to guide nurses' quality improvement activities (Irvine, Sidani, McGillis Hall, 1998b), and for curriculum design of a graduate course on quality improvement of nursing services. For example, the model was used to guide improvement of nursing care of patients who were post-coronary artery catheterization. An evaluation of a cognitive-behavioral intervention indicated improved confidence in nursing assessment, diagnosis and management of complications related to catheterization and arterial catheter site care.

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