Nursing Care Delivery Models: Canadian …/media/cna/page-content/pdf-en/nursing...Nursing Care Delivery Models: Canadian Consensus on Guiding Principles cna-aiic.ca

Nursing Care Delivery Models: Canadian Consensus on Guiding Principles

cna-aiic.ca

The opinions and interpretations in this publication are those of the author

and do not necessarily reflect those of the Government of Canada.

Funded by the Government of Canada’s Foreign Credential Recognition Program.

This report was produced by CNA to provide information on a particular topic or topics. The views and opinions

expressed in this report do not necessarily reflect the views of the CNA board of directors.

All rights reserved. One copy of this document may be reproduced or downloaded for your non-commercial personal use. Further reproduction in any

manner, including stored in a retrieval system or transcribed, in any form or by any means, mechanical, recording or otherwise, is prohibited without

prior written permission of the publisher. Permission may be obtained by contacting CNA at [email protected].

A copy of the Delphi 1 and 2 surveys and full summary reports of results for

Delphi 1 and Delphi 2 are available from CNA upon request at [email protected].

© Canadian Nurses Association

50 Driveway

Ottawa, ON K2P 1E2

Tel.: 613-237-2133 or 1-800-361-8404

Fax: 613-237-3520

Website: www.cna-aiic.ca

March 2012

ISBN 978-1-55119-376-2

Canadian Nurses Association i

Table of Contents

Abstract ............................................................................................................................................... 1

Introduction ......................................................................................................................................... 2 Objectives ............................................................................................................................... 2

Delphi 1 .............................................................................................................................................. 3 Methodology ........................................................................................................................... 3 Delphi 1 results ....................................................................................................................... 5 Delphi 1 findings..................................................................................................................... 6

Delphi 2 ............................................................................................................................................ 10 Methodology ......................................................................................................................... 10 Delphi 2 results ..................................................................................................................... 11 Delphi 2 findings................................................................................................................... 12

Discussion ......................................................................................................................................... 15 Key Messages ....................................................................................................................... 16

Appendix A: Demographic Profile of Delphi Respondents ............................................................... 18

Appendix B: Results of Delphi 1....................................................................................................... 22

Appendix C: Results of Delphi 2....................................................................................................... 30

Appendix D: Randomly Ordered List of 10 Principles as Presented in Delphi 2 Survey ................... 35

References ......................................................................................................................................... 36

List of Tables

Table 1: Nursing Care Delivery Models Guiding Principles ............................................................ 17

Table A.1: Distribution of respondents by jurisdiction compared with national distribution of registered nurses ............................................................................................................................... 18

Table A.2: Distribution of respondents by geographic description .................................................... 19

Table A.3: Distribution of respondents by professional designation ................................................. 19

ii Nursing Care Delivery Models: Canadian Consensus on Guiding Principles

Table A.4: Distribution of respondents by area of responsibility compared with national distribution of nurses ............................................................................................................................................... 20

Table A.5: Distribution of respondents by place of work ................................................................. 20

Table A.6: Distribution of respondents by age compared with distribution of nurses in Canada ...... 21

Table A.7: Distribution of respondents by years in nursing ............................................................. 21

Table B.1: Results of Delphi 1 survey on 18 draft principles ........................................................... 22

Table C.1: Delphi 2 ranking of 10 consolidated principles ......................................................... 30

Table C.2: Delphi 2 results: In your opinion how would you describe each principle below using the

following definitions? ....................................................................................................................... 34

Canadian Nurses Association 1

Abstract

A two-round Delphi process was used with the aim of achieving consensus on principles to guide decision-making about nursing care delivery models. The Delphi 2 survey asked respondents to prioritize the top four principles from a list of 10 principles established in Delphi 1. Analysis of the rankings involved average weighted responses; percentage rated as first principle; and percentage rated in the top four. Consensus was qualified because respondents considered all 10 guiding principles important. The principles ranked according to the weighted scores are:

Guiding principles for decision-making about nursing care delivery

1. Responding to the health-care needs of clients, families and communities is integral to the nursing care delivery model.

2. Staff competencies (knowledge, skills, abilities, attitudes) are a part of the nursing care delivery model.

3. The nursing care delivery model reflects an organization’s client population, best practices, professional standards and research evidence.

4. Front-line nursing staff and nursing management are engaged in decision-making about the nursing care delivery model.

5. The nursing care delivery model promotes quality and safe care, which is cost-effective and sustains the system.

6. Systematically collected data about client outcomes and nursing human resources inform decisions about the nursing care delivery model.

7. A formal plan for the nursing care delivery model, including communication and educational strategies, considers client and staff needs as well as the organizational mission.

8. Organizational structure and leadership across all levels support the nursing care delivery model.

9. Staff mix based on client care needs is a component of the nursing care delivery model.

10. Technology is a required component for implementing the nursing care delivery model.

2 Nursing Care Delivery Models: Canadian Consensus on Guiding Principles

Introduction

A nursing care delivery model has been described as a structured approach for organizing and providing nursing care to clients, informed by values and beliefs (Jost, Bonnell, Chacko & Parkinson, 2010). Nursing care delivery models underpin decisions about many aspects of delivering nursing services.

The Canadian Nurses Association (CNA) wants to facilitate the transfer of knowledge related to nursing care delivery models and staff mix into practice. CNA is committed to collaborating with nursing experts throughout Canada across the continuum of care sectors, practice settings and roles.

This project builds on three CNA initiatives:

1. Invitational Round Table — Nursing Care Delivery Models and Staff Mix: Using Evidence in Decision-making (2011)

2. core principles for a draft revised staff mix decision-making framework authored by a working group composed of registered nurses (RN),1 licensed practical nurses (LPN),2 registered psychiatric nurses (RPN),3 unregulated care providers (UCP) and a nurse researcher

3. results of a preliminary literature review

The goal of this project was to develop Canadian consensus on the principles that guide policy-makers and managers in decision-making about nursing care delivery models.

Objectives

to achieve consensus among a convenience sample of nursing experts in practice, policy, research, administration and education on a set of guiding principles related to nursing care delivery models;

to collaborate with nurses across Canada; and

to advance comprehensive, evidence-based decision-making related to the development, implementation and evaluation of nursing care delivery models.

CNA chose to use the Delphi process, a systematic, interactive methodology for exploring issues and building consensus.4 The team that guided and supported the project included an external research consultant, two CNA nurse advisors, a CNA board representative and a CNA administrative assistant.

1 Licensed practical nurse or LPN is a term used in most of Canada. This category is called registered practical nurse in Ontario and infirmier auxiliaire/infirmière auxiliaire in Quebec. LPN as used in this paper includes these two categories. 2 Registered psychiatric nurses or RPNs are regulated in Canada’s four western provinces — Manitoba, Saskatchewan, Alberta and British Columbia — as well as in the Yukon. RPN as used in this paper describes this category of nurse. 3 Unregulated care provider or UCP is used to describe paid health-care providers who are not registered with a regulatory body. It should be noted that UCPs are known by many other titles and include, but are not limited to: health-care aides; resident aides and home support workers. 4 The Delphi technique is a widely used and accepted method for gathering data from respondents within their domain of expertise. The technique

is a group communication process that aims to achieve convergence of opinion on a specific real-world issue (Hsu & Sandford, 2007).


Delphi 1

Methodology

Step 1: Generating the survey items

The project team met in March 2011 to determine what items to include in the Delphi 1 survey. Using a nominal group process adapted from the Institute of Cultural Affairs (1998), the project team discussed the ideas generated at CNA’s October 2010 Invitational Round Table — Nursing Care Delivery Models and Staff Mix: Using Evidence in Decision-making (2011), the list of principles proposed by the staff mix working group, and the issues identified in a preliminary literature review. The team clarified meanings, insights and interpretations, and produced a thematic analysis of the results by:

clustering principles, reviewing the ideas and removing those that did not fit into the cluster, sometimes revealing a new cluster or broadening an existing cluster;

discerning the focus of each cluster and assigning it a theme; and

reviewing and reflecting on the items in the themes and confirming or correcting the clusters.

Step 2: Developing the Delphi 1 survey

Generally accepted principles of survey design (such as avoiding double questions in any item) were used to draft the survey. The final version of the Delphi 1 survey consisted of 18 principles with four to 15 sub-categories that were intended to explain the scope of the principle. Each list of items included an “other” category to enable respondents to add to the list.

Using a four-point Likert scale with the labels very important, important, less important or not important, respondents were asked to rate:

the importance of each draft principle related to design, selection and implementation of nursing care delivery models; and

the importance of the sub-categories associated with each principle.

In addition, respondents were invited to comment on each principle as well as comment on the entire set of guiding principles at the end of the survey.

The introduction to the survey assured respondents that the data they provided would remain confidential and anonymous. It also stated that the project consultants would provide a summary report


of the results, would not associate responses with individuals, and would conduct analyses on all surveys whether partially or fully completed.

The introduction, questions and e-mail announcements were reviewed for readability and translated into French by CNA Corporate Communications. The questions were uploaded to the FluidSurveys online survey tool.

Step 3: Testing the survey

The draft Delphi 1 survey was pre-tested by four nursing experts to assess if the items were understandable, unambiguous and comprehensive. Based on the experts’ written suggestions and teleconference debriefing, the team adjusted the survey, including wording, order and the addition of some sub-categories. Pre-test respondents estimated that 30 minutes would be required to complete the survey.

The survey then was distributed in English and French to 25 nursing experts who were known by CNA to be interested in the issue of nursing care delivery models. This pilot study was scheduled to be open from April 1 to 11, 2011, but was extended to April 21 to accommodate a special request. There were 13 respondents in total. It was confirmed that the average time to complete the survey was less than 30 minutes. All comments and suggestions were reviewed and considered for inclusion in the final version of the survey. It was decided that further testing was not required as the resulting revisions did not change the survey appreciably.

Step 4: Distribution

The invitation to participate in Delphi 1 was sent by e-mail to a convenience sample of nursing experts in practice, policy, research, administration and education; the addressees were also invited to encourage their colleagues to participate by forwarding to them the cover message with the link to the survey (a recruitment approach called snowball methodology). The survey was open from May 9 to 23, 2011.

One week later, a reminder/thank you message was sent using the same distribution method as was used for the original survey. The message thanked people for their participation if they had completed the survey and reminded them to complete it, if they had not already done so. A few days before the closing deadline, the survey was announced in the May issue of CNA Now, which included a link to the survey to facilitate response.

Step 5: Analyzing the responses

Because the goal was to find consensus, the average of the Likert scores for each principle is not meaningful. Instead, the analysis is based on percentage of responses. The number and percentage of responses was calculated for each of the Likert scale options and simple statistical analysis was conducted to determine the mean, median, variance and standard deviation (SD) using Excel.


Delphi 1 results

For Delphi 1, there were 358 completed and 85 incomplete surveys for a total of 443; 11 were answered in French and 432 in English. The count for incomplete surveys does not include those with two or fewer questions answered. Respondents took 25 minutes on average to complete the survey.

Respondent demographic profile

The geographic distribution of the respondents is shown in Appendix A, Table A.1. Compared with Canadian Institute for Health Information (CIHI) statistics for regulated nurses in 2009 (2010a), respondents were underrepresented in British Columbia, Ontario and Quebec but overrepresented in Atlantic Canada, Manitoba, Saskatchewan, the Northwest Territories and the Yukon. Most respondents (73.2%) were from urban areas (see Table A.2).

Respondents were RNs, including nurse practitioners (NP) (93%), followed by LPNs (2.5%) and RPNs (4.2%) (see Table A.3). UCPs represented 0.3% of Delphi 1 respondents.

Management and academic positions were overrepresented in comparison with the CIHI 2009 profile (see Table A.4). Management provided the most responses (33.2%); combined front-line nurses and front-line support represented 43.9% of respondents; and nurses working in academia provided 15.9% of the responses. Some respondents listed their role as “other” and some reported that they work in more than one role.

Sector responses may not reflect employment patterns in Canada. As shown in Table A.5, 43.2% of Delphi 1 respondents were from acute care and 25.1% from community health. By comparison, CIHI reported that 14.2% of all Canadian nurses worked in community health in 2009 (2010a, p. 20). The large number of respondents that listed themselves as “other” (29.7%) may have distorted the calculation of distribution by sector because the CIHI study would have assigned these respondents to one of its categories. The list of “other” responses was not analyzed for potential redistribution.

The median age range of respondents to the Delphi 1 survey was 50 to 54 years (27%), which is older than the 2009 median age range of 45 to 49 years of nurses employed in Canada (CIHI, 2010b) (see Table A.6). The majority of respondents had more than 20 years of experience in nursing (73.3%) (see Table A.7).

For Delphi 1, 52% of respondents had been involved in nursing care delivery model redesign within the past five years and 48% had not.


Delphi 1 findings

The principles and sub-categories listed in the survey and a summary of findings is available from CNA. Appendix B in this document is a table listing each of the 18 principles presented in the Delphi 1 survey and the percentage of responses that indicated that principle was “very important.” For a better understanding of each principle, selected details regarding sub-category items are included in the table. The median score on 16 out of 18 items was “very important” but the overall SD varied from 0.280 to 0.851.

For 75% or more respondents, nine out of 18 principles were rated as very important; the SD for all of these was less than 0.5. More than 91% of respondents rated 17 out of 18 principles as important or very important. The exception was the item about what level of staff should be involved in decision-making about nursing care delivery models. Although 28% of respondents agreed that it was very important for chief executive officers (CEO) to be involved, the SD of 0.851 was higher than any other SD measured. Agreement on CEO involvement rose to 67% when important and very important were combined. However, 92% (SD = 0.280) of respondents concurred that it was very important to include front-line nursing staff in these decisions and the score rose to 100% when very important and important were combined. Nursing managers’ involvement in decision-making about nursing care delivery models was very important for 83% of respondents; again, the score rose to 100% when important and very important were combined.

Although parametric tests were not run on differences in responses, cross-tabulations of responses revealed differences by provincial and territorial jurisdiction, professional designation, employment role/position, age, years in nursing and health-care sector. To demonstrate the response variation, the highest and lowest percentage responses within each item are shown in Table B.1 in Appendix B.

For example, on using “systematically collected data...inform...nursing care delivery models,” the smallest differences were among different roles and the largest differences were between provinces and territories. That is, Alberta respondents (85%) were most likely to agree and New Brunswick respondents least likely (52%).

For using evidence about client outcomes, the greatest differences were between British Columbia respondents (62%) and Prince Edward Island respondents (93%). Differences were minimal between urban and rural responses or among different professional groups.

Respondents from Quebec and the Northwest Territories were more likely to recommend involving CEOs and chief nursing officers in the decision-making about nursing care delivery models than were respondents from other jurisdictions, while respondents from Prince Edward Island and New Brunswick were more likely to include program directors. Respondents from Prince Edward Island, Quebec, Nova Scotia and New Brunswick agreed that it was very important for nursing care delivery models to be designed to contribute to long-term sustainability of the health-care system.


With respect to incorporating staff competencies “into [nursing care delivery] model design,” the largest differences were between jurisdictions (Prince Edward Island at 100% compared with Quebec at 67%) and age groups (55 to 59 years at 88% compared with 30 to 34 years at 50%), but there was little difference between respondents with different professional designations or between sectors.

Opinions about “organizational structure [supporting] the nursing care delivery model” and using evidence-based decision-making varied between provinces and territories, professional designations and age groups, but there was little difference between people with different roles or working in different sectors.

On questions where there were lower ratings on the Likert scale, there was generally larger variation in responses, between provinces and territories, roles, and age groups. Examples include the model: needing to support “long-term sustainability;” to “reflect the context of care;” to be “compliant with sector requirements” (e.g., legislation); implemented with the use of “technology” and supported by “a corporate communication plan.”

Principles with the least variation included the importance of “staff members [being] engaged in decision-making about nursing care delivery models;” the importance of the nursing care delivery model being “responsive to clients;” and “staff mix decisions...[being] based on client care needs.”

Selected respondent comments

Comments can be classified in the following theme areas:

1. Regarding the survey

Positive comments:

– “Well-done.” “An excellent first Delphi survey!” “Very comprehensive.” “Relevant areas were covered: well thought out and presents as a valid concept.”

– “Pleased to be part of this survey. Gives me hope that we are making decisions based on evidence and not just on $$.”

– “Thank you.”

The challenges of the nursing care delivery model project:

– “In an ideal world everything is very important; however, in reality there is a need to establish priorities.”

– “Difficult to find an area listed that would not be very important toward a comprehensive care model.”

– “Lengthy questionnaire.”


Interdisciplinary issues:

– “A ‘nursing care delivery’ model only makes sense as part of a broader, interdisciplinary, intersectoral care delivery model; the model seems insular to nursing. Any model must be a multidisciplinary model.”

– “It needs more emphasis on interprofessional models.”

– “It would seem more appropriate to call it a patient care delivery model — particularly as we work with the interdisciplinary team in developing and implementing the patient’s care plan and meeting [patient] needs.”

2. Skepticism

“It is all nice in theory — but reality is that no one re-evaluates.”

“My work experience with some nursing care delivery models in the past is that they were not adaptable to all types of clients, and were focused mainly on saving [money].”

“The questionnaire would provide much more dynamic information if it was based on the ‘reality’ rather than the ideal.”

3. Comments that expand on the survey responses

Flexibility to meet different client needs:

– “A nursing care delivery model has to be adaptable to different clients.”

– “Needs to be flexible and focus on patients first.”

– “CDM [care delivery model] must be considered within the context of practice (i.e., acute care facility with high acuity vs. long-term care) where patients can be stable for many years.”

– “Do not make the assumption that there should be a single care delivery model for a whole organization.” “May vary according to contextual factors.” (frequent comment)

– “There is no one universal model of care that would be adopted by the organization. In reality there are infinite models of care which are developed and implemented based on contextual factors and may vary with the organization depending on these contextual factors.”

Front-line involvement:

– “Very important to have front-line staff buy-in!!”

– “More front-line nurses need to be involved in planning nursing models.”

“Patient safety is number one priority joined with nurse safety.”

“The patient, family and community must be vitally involved… have a say in what is to be the delivery of care.”


4. RN and LPN roles

“At this time, pressure is exerted on schools of nursing to allow BScN students (learning how to be future RNs) to be preceptored by LPNs. This unacceptable practice must be assessed and evaluated.”

“The principles do not yet specifically get at the current confusion and overlap of nursing roles — name changes to LPN, RN (for instance) may be needed along with work on clarifying and adapting these roles.”

“The current model of RN/LPN collaboration used on my ward is ineffective — we need to clearly outline what an RN can do differently and what is expected of RNs.”

5. Other

“What will be important, however, is to ascertain what is actually happening in practice. E.g., there may be 100% agreement on the importance of the content included in this survey but the critical question is: To what extent are people actually applying/using/following the principles when they make changes?”


Delphi 2

Methodology

Step 1: Developing the Delphi 2 survey

For the Delphi 2 survey, the project team consolidated by theme the 18 Delphi 1 principles into the 10 Delphi 2 principles. Presented in a random order for Delphi 2, the consolidated principles incorporated all principles rated as very important or important for design, selection, implementaton and evaluation of nursing care delivery models by more than 90 per cent of Delphi 1 respondents (see Appendix C).

The first question was designed as a two-step process that invited respondents to identify the top four out of the 10 most important principles initially and then to prioritize their list from one to four. In the second question, respondents were asked to differentiate: (a) those principles that are essential for a nursing care delivery model design; (b) those principles that address implementation or evaluation of a nursing care delivery model; and (c) those principles where both design and implementation/evaluation apply.

As in Delphi 1, the introduction, questions and e-mail announcements were reviewed for readability, translated into French, and uploaded to the FluidSurveys online tool.

Step 2: Testing the survey

The Delphi 2 survey was sent for pre-testing in English and French to eight nursing experts who had no previous knowledge about the first survey. Based on the experts’ written suggestions and a teleconference debriefing of four of the respondents, some wording was adjusted. These experts estimated that approximately 15 minutes would be required to complete this survey.

Step 3: Distribution

Delphi 2 was distributed to the same list of names as Delphi 1 with a similar invitation to forward the survey link to colleagues. For Delphi 2, the Canadian Healthcare Association and the Canadian Council for Practical Nurse Regulators distributed the link to the survey and encouraged participation, something not done for Delphi 1. This added recruitment may account for the much higher response to Delphi 2. Consistent with Delphi 1, a reminder/thank you message was sent. The survey was open from June 20 to July 3, 2011.


Step 4: Analyzing the results

For Delphi 2, the responses were collated and ranked using three methods:

1. average weighted score for each for the 10 guiding principles (Weighting was calculated by multiplying the top-ranked principle for each respondent by 4, the second-ranked principle by 3, the third-ranked principle by 2 and the fourth-ranked principle by 1. The total of all scores for each principle was divided by the number of respondents to calculate the average score for each principle.);

2. percentage of total responses that ranked each of the 10 guiding principles as first priority; and

3. percentage of total respondents that ranked each principle as one of the top four.

Delphi 2 results

Delphi 2 yielded 1,897 completed and 396 incomplete surveys for a total of 2,293 responses; 19 surveys were answered in French and 2,274 were answered in English. Respondents took 10 minutes on average to complete the survey.

Respondent demographic profile

Of the respondents, 419 did not complete the demographic question about jurisdiction, which means that there is not a clear picture of the distribution across Canada. For those who answered this question, most were from Ontario (59.2%), followed by Alberta (20.6%), with at least some representation from all other provinces and territories as shown in Appendix A, Table A.1. Respondents in urban areas completed 76.4% of surveys (see Table A.2).

As shown in Table A.3, 77.7% of respondents were RNs, including NPs. LPN participation increased from 2.5% in Delphi 1 to 19.5% in Delphi 2. RPN participation, however, decreased from 4.2% in Delphi 1 to 1.8% in Delphi 2. The representation of UCPs in Delphi 2 increased marginally from 0.3% to 0.5%.

Reponses from management (17.2%) were overrepresented compared with the 2009 CIHI profile (2010a, p. 21), which shows 6.5% of RNs working in administration. The 69.9% combined front-line staff respondents (56.7% front-line and 13.2% support to front-line practitioners) under-represents the 89.3% of RNs in Canada that provide direct care (see Table A.4).

The respondents’ median age range was 45 to 49 years (17.9%), which falls within the median age range of nurses in Canada (see Table A.6); the majority of respondents (58.9%) had more than 20 years of experience in nursing (see Table A.7).


As shown in Table A.5, 20.1% of Delphi 2 respondents were from community health, compared with 14.2% of all Canadian nurses working in community health (CIHI, 2010a, p. 20). A large portion (22.0%) of respondents listed themselves as “other.”

For Delphi 2, 42% of respondents had been involved in nursing care delivery model redesign and 58% had not.

Delphi 2 findings

The priority ranking for the 10 guiding principles varies slightly depending on the methodology used (average weighted scores, percentage that gave the principle the highest ranking, or percentage of respondents that gave the principle a ranking of 1 to 4). But no matter which methodology is used, the same principles ranked in the top four; in fact, more than half of the respondents ranked each of those principles in the top four. Table C.1 in Appendix C presents the results of the three methodologies, with the principles presented in the order according to average weighted scores, as well as the highest and lowest percentage response (not weighted) according to demographic characteristics for Delphi 2.

As in Delphi 1, parametric testing of results was beyond the scope of this project. However, the analysis examined differences in percentage response by demographic characteristics. Full details on the responses by demographic characteristics are available by contacting CNA at [email protected].

For the highest-ranked principle — “responding to the health-care needs of clients, families and communities is integral to the nursing care delivery model” — there were contrasting responses between demographic groups. Saskatchewan respondents (86%) were most emphatic and Newfoundland and Labrador respondents (45%) were least emphatic. For professional designation, LPNs (66%) felt strongest about the ranking of this principle and RPNs (15%) gave it the least support.

On the issue of “staff competencies (knowledge, skills, abilities, attitudes),” LPN respondents (74%) were most likely to rate the principle as a top priority; UCPs were least likely (7%). The differences between jurisdiction, age group and years of experience were less than 20 percentage points.

For the principle “The nursing care delivery model reflects an organization’s client population, best practices, professional standards and research evidence,” there were differences according to provincial and territorial jurisdiction, professional designation, age group and sector. This principle was prioritized by NPs (63%) most and UCPs least (8%); 40- to 44-year-olds (58%) most and those younger than 25 least (32%); and respondents from the government sector (74%) most and those from long-term care least (48%).

Although the principle “front-line nursing staff and nursing management are engaged in decision-making about the nursing care delivery model” scored as one of the four highest-rated guiding


principles, there were noticeable differences according to jurisdiction and health-care sector. Respondents from Prince Edward Island (85%) were most likely to prioritize this principle and those from New Brunswick (57%) were least likely; acute care respondents (67%) were most likely and government sector respondents were least likely (47%). Differences between professional designations, age groups and years of experience were 15 percentage points or less.

“Systematically collected data about client outcomes and nursing human resources” was reported as a higher priority most often by respondents from Prince Edward Island (54%) and least often by Newfoundland and Labrador respondents (14%). By sector, it was a higher priority most often for government respondents (32%) and least often for long-term care respondents (14%). Differences between professional designations, roles, age groups and years of experience were 12 percentage points or less.

Including “a formal plan for the nursing care delivery model” was most often rated as a priority for Quebec respondents (67%) and least often for Nova Scotia respondents (24%). Demographic analysis of other categories, including professional designation, role, age, experience and health-care sector, revealed differences of 15 percentage points or less.

Rating the “staff mix based on client care needs…[as] a component of the nursing care delivery model” was 15 percentage points or less different for all demographic characteristics except for geographic setting. Staff mix was rated as important for 44% of the remote/isolated respondents compared with 25% of urban — inner city respondents.

The percentage responses by the various demographic characteristics differed by 16 percentage points or less for the principles about: the nursing care delivery model promoting “quality and safe care, which is cost-effective and sustains the system;” the “organizational structure and leadership across all levels…[of the organization supporting] the nursing care delivery model;” and technology supporting nursing care delivery models.

As shown in Table C.2, respondents to the second question in Delphi 2 did not conclusively describe the principles according to the options suggested (design principle, implementation/evaluation principle, or both design and implementation/evaluation principle). Between 43% and 59% rated principles as a combination of design and implementation/evaluation principles. For the five principles where less than 50% responded that they were both, there was no agreement about which of the two categories the principles would fall into: 23-36% were rated as design options and 17-26% were rated as implementation/evaluation options.


Selected respondent comments

The qualitative comments for Delphi 2 can be grouped into the following themes:

1. Appreciation for the work

“Thank you for doing this survey.”

“Interesting and thought-provoking questions.”

“Am pleased that the opinions of nurses across Canada are being considered in this issue.”

2. Issues that are already incorporated in the survey results

importance of front-line staff involvement (most frequent comment);

importance of addressing needs of clients; and

promoting health-care teams, safety, accountability and regular evaluation.

3. Areas beyond the scope of this nursing care delivery models project

“Work environments.”

“Scope of practice for LPNs.”

4. Skepticism

“Nursing care delivery model is too often used to justify staff mix that has addressed budgetary issues instead of using NCDM to determine staff mix.”

“Quality care is no longer a factor — has been about money from the start.” (second most frequent comment)

“Leadership ask staff opinions but ignores what is said.”

“I’m not convinced that the ‘nursing care delivery model’ is relevant to most of us in day-to-day nursing. I’d like a return to good leadership, management and evidence-based practice.”

5. Survey design

“The wording in the survey was challenging and not friendly.”

“Well-worded survey. Thank you for including clear definitions.”


Discussion

The goal of achieving consensus on principles to support decision-making on nursing care delivery models was reached in Delphi 1. The Delphi 2 consultation went an extra step in asking the participants to prioritize a consolidated list of the principles for which consensus had already been achieved.

Although the criterion for consensus varies, typically at least 70% agreement — and often 80% agreement — is considered acceptable (Hsu & Sandford, 2007, p. 4). The >90% agreement of the Delphi 1 survey endorses the recommendations from Invitational Round Table — Nursing Care Delivery Models and Staff Mix: Using Evidence in Decision-making, the staff mix working group, and the issues identified in the preliminary literature review. These results demonstrated that the previously identified issues about nursing care delivery models are relevant for Canadian nurses regardless of their geographic area, professional designation, health-care role, age group, years in nursing and sector.

The Delphi 2 respondents stated that it was difficult to choose the top four consolidated principles, but 52% to 65% respondents ranked in the top four the same principles that yielded the highest weighted scores. Each of the 10 guiding principles was ranked as a top four priority by some of the respondents (12% to 65%). Although the Delphi 1 consensus supports the list of principles, the Delphi 2 priority ranking did not meet the consensus criterion of at least 70%. One can, therefore, conclude from these results that decision-making about nursing care delivery models should adhere to all 10 consolidated principles.

Although the project team had hoped to sort the list of principles into smaller categories, the Delphi 2 responses revealed that the 10 principles are not readily divided into design principles and implementation/evaluation principles.

The results do show that health-care needs of clients, families and communities are vital to nursing care delivery models. This project also provides resounding evidence to support front-line nursing staff involvement in all steps of the decision-making process related to nursing care delivery models. What the respondents made clear is that the people who work the most closely with clients have very important contributions to make regarding decisions about nursing care delivery models.

The extensive participation in this project demonstrated the high level of interest, especially by nurses, in the topic of nursing care delivery models. The lower proportion of participation for RN respondents in Delphi 2 compared with Delphi 1 can be attributed to the increase in participation of LPNs and does not indicate less interest by RNs. The results are highly credible because the majority of respondents in both rounds were very experienced (73% of Delphi 1 and 59% of Delphi 2 respondents had more than 20 years of nursing experience). The 22% of respondents that listed “other” for place of work may have distorted the calculation of the distribution of respondents according to sector. Although the distribution of respondents does not exactly match the 2009 profile of nurses across Canada (CIHI, 2010a), there were participants from every geographic region in Canada and from a broad range of


health-care roles, age groups and years of experience. The enthusiastic response to the Delphi surveys may also be partly attributed to the many Canadian nurses who have already been involved in nursing care delivery model redesign (52% of Delphi 1 respondents and 42% of Delphi 2 respondents).

Although analysis of the qualitative comments was beyond the scope of this project, some clear messages came through. Administrators will likely be concerned about the skepticism voiced by respondents that front-line staff members are not being listened to.

Many also noted that interdisciplinary model planning should be emphasized and nursing care delivery models cannot be designed in isolation. Models must be flexible and no one model will fit the needs of every client group. In addition, respondents pointed to the need for evaluation of nursing care delivery models.

Key Messages

The enthusiastic participation in this project signals that Canadian nurses are ready, willing and able to participate in the development, selection, implementation and evaluation of nursing care delivery models. That enthusiasm can be leveraged to establish effective care delivery models that in turn should improve client care and health outcomes.

Nursing care delivery models need to be flexible in order to meet different client needs.

Nursing care delivery models must consider the interdisciplinary nature of health care.

The results of this project suggest that it is important to consider all 10 of the guiding principles when making decisions about nursing care delivery models. These principles (see Table 3 below) are numbered for convenience rather than to confer ranking by priority, although they are ordered according to the weighted scores.


Table 1: Nursing Care Delivery Models Guiding Principles

1. Responding to the health-care needs of clients, families and communities is integral to the nursing care delivery model.

2. Staff competencies (knowledge, skills, abilities, attitudes) are a part of the nursing care delivery model.

3. The nursing care delivery model reflects an organization’s client population, best practices, professional standards and research evidence.

4. Front-line nursing staff and nursing management are engaged in decision-making about the nursing care delivery model.

5. The nursing care delivery model promotes quality and safe care, which is cost-effective and sustains the system.

6. Systematically collected data about client outcomes and nursing human resources inform decisions about the nursing care delivery model.

7. A formal plan for the nursing care delivery model, including communication and educational strategies, considers client and staff needs as well as the organizational mission.

8. Organizational structure and leadership across all levels support the nursing care delivery model.

9. Staff mix based on client care needs is a component of the nursing care delivery model.

10. Technology is a required component for implementing the nursing care delivery model.


Appendix A: Demographic Profile of Delphi Respondents

Table A.1: Distribution of respondents by jurisdiction compared with national distribution of registered nurses

Province/Territory

Registered nurse workforce by jurisdiction

in Canada in 2009*

n = 266,341

Delphi 1 respondents by jurisdiction

Total = 443 n = 358 + 85 not stated

Delphi 2 respondents by jurisdiction

Total = 2,293 n = 1,897 + 396 not stated

Newfoundland and Labrador 2.2% 6.4% 1.6%

Prince Edward Island 0.5% 4.2% 0.7%

Nova Scotia 3.4% 14.3% 4.5%

New Brunswick 3.0% 5.9% 4.5%

Quebec 24.8% 1.7% 0.5%

Ontario 35.4% 30.5% 59.2%

Manitoba 4.2% 10.1% 2.8%

Saskatchewan 3.4% 6.4% 1.9%

Alberta 11.0% 11.5% 20.6%

British Columbia 11.6% 5.9% 3.2%

Yukon 0.1% 2.0% 0.1%

Northwest Territories/Nunavut 0.4% 1.1% 0.4%

Total 100.0% 100.0% 100.0%

* Source: Canadian Institute of Health Information. (2010). Regulated nurses: Canadian trends, 2005 to 2009. Ottawa: Author, p. 13. Retrieved from http://secure.cihi.ca/cihiweb/products/nursing_report_2005-2009_en.pdf


Table A.2: Distribution of respondents by geographic description

Delphi 1: n = 357 Delphi 2: n = 1,893

Urban — inner city 148 41.5% 743 39.2%

Urban — other 114 31.9% 704 37.2%

Rural 95 26.6% 442 23.3%

Remote/isolated 13 3.6% 42 2.2%

Other 20 5.6% 94 5.0%

Total 390 109.2%* 2,025 106.9%*

* Percentage totals may not equal 100% because some respondents chose more than one geographical description.

Table A.3: Distribution of respondents by professional designation

Delphi 1: n = 357 Delphi 2: n =1,897

Registered nurse 86.6% 73.3%

Nurse practitioner/RN (EC) 6.4% 4.4%

Licensed practical nurse* 2.5% 19.5%

Registered psychiatric nurse 4.2% 1.8%

Unregulated care provider 0.3% 0.5%

Other 4.5% 4.1%

Total 104.5%** 103.6**

* Licensed practical nurse also refers to registered practical nurse in Ontario.

** Percentage totals may not equal 100% because some respondents chose more than one professional designation.


Table A.4: Distribution of respondents by area of responsibility compared with national distribution of nurses

Registered nurse workforce by area of responsibility in 2009*: n = 266,341

Delphi 1 respondents by position: n = 357

Delphi 2 respondents by position: n = 1,886

Direct care 89.3% Front-line or field staff 26.3%

Support to front line 17.6%

Total 43.9%

Front-line or field staff 56.7%

Support to front line 13.2%

Total 69.9%

Administration 6.5% Management (includes from supervisor to president) 33.2%

Management (includes from supervisor to president) 17.2%

Education and research 4.3% Academic (research, education) 15.9% Academic (research, education) 7.6%

Other 6.7% Other 5.2%

Total 100.1** Total 99.7%** Total 99.9%**


** Percentage totals may not equal 100% due to rounding.

Table A.5: Distribution of respondents by place of work

Canada* Delphi 1: n = 354 Delphi 2: n = 1,878

Acute care (hospital)

62.6% 153 43.2% 1,012 53.9%

Long-term care/ nursing home

9.9% 46 13.0% 294 15.7%

Community health 14.2% 89 25.1% 377 20.1%

Government Not reported 29 8.2% 53 2.8%

Other 13.8% 105 29.7% 414 22.0%

Total 100.5%** 422 119.2%** 2,150 114.5%**


** Percentage totals may not equal 100% because some respondents chose more than one place of work.


Table A.6: Distribution of respondents by age compared with distribution of nurses in Canada

Age

Registered nurse workforce by age in Canada in 2009*:

n = 266,341 Delphi 1 respondents by age:

n = 333 Delphi 2 respondents by age:

n = 1,873

<30 11.6% 1.8% 9.0%

30-34 9.7% 5.4% 6.5%

35-39 11.2% 3.9% 8.1%

40-44 12.8% 15.6% 10.1%

45-49 14.9% median age 15.6% 17.9% median age

50-54 15.4% 27.0% median age 19.8%

55-59 14.0% 22.5% 17.6%

60+ 10.5% 8.1% 11.1%

Canada 100.1%** 99.9%** 100.1%**


** Percentage totals may not equal 100% due to rounding.

Table A.7: Distribution of respondents by years in nursing

Years in nursing Delphi 1 respondents: n = 358 Delphi 2 respondents: n = 1,873

Less than one year 0.6% 3.1%

1-5 years 3.1% 9.7%

6-10 years 7.6% 10.1%

11-15 years 5.9% 8.8%

16-20 years 9.6% 9.5%

More than 20 years 73.3% 58.9%

Total 100.1%* 100.1%*

* Percentage totals may not equal 100% due to rounding.


Appendix B: Results of Delphi 1

Table B.1: Results of Delphi 1 survey on 18 draft principles

(includes highest and lowest percentage “very important” by province or territory, geographic type, role description, professional designation, age, years in nursing and health-care sector)

Delphi 1 draft principles Underlined text indicates the main point of the principle. Sub-categories that explain the scope of the principle are shown in abbreviated form in parentheses.

Percentage of responses indicating that the principle was very important Standard deviation (SD) is shown in parentheses. See summary report for statistics.

Highest and lowest percentage response of very important by province or territory, geographic type, role description, professional designation, age, years in nursing and health-care sector Results not included for fewer than five respondents in a category or for “other.” Some respondents reported more than one category for geographic type (i.e., urban or rural), professional designation and health-care sector.

Highest percentage Lowest percentage

1. Systematically collected data are used to inform decision-making about nursing care delivery models. (baseline data, after-care data, updated & ongoing data, etc.)

71% (SD = 0.482) Alberta 85% Remote/isolated 77% Management 71% Nurse practitioners 83% 35-39 years old 100% >20 years in nursing 72% Government 76%

New Brunswick 52% Rural 62% Support to front-line practitioners 53% Registered nurses 69% 60+ years old 52% 1-5 years in nursing 45% Long-term care 43%

2. Decisions are informed by evidence on client outcomes. (rate of restraint utilization, falls rate, length of stay, etc.)

80% (SD = 0.419) Prince Edward Island 93% Urban — inner city 77% Academic 81% Registered nurses 78% 60+ years old 85% 16-20 years in nursing 79% Government 83%

British Columbia 62% Urban — other 75% Front-line nurses 67% Licensed practical nurses 63% 30-34 years old 56% 6-10 years in nursing 63% Long-term care 61%

3. Staff members are engaged in decision-making about nursing care delivery models.

Chief executive officer

28% (SD = 0.851)

Quebec 50% Remote/isolated 31% Academic 37% Registered nurses 31% 35-39 years old 38% 6-10 years in nursing 33% Community health 30%

Saskatchewan 18% Rural 28% Front-line or field staff 17% Registered psychiatric nurses 7% 40-44 years old 21% 16-20 years in nursing 18% Acute care 26%








Chief nursing officer

55% (SD = 0.656)

Quebec 83% Urban — other 58% Management 63% Nurse practitioners 61% 60+ years old 67% 16-20 years in nursing 65% Government 66%

British Columbia 29% Remote/isolated 46% Front-line or field staff 36% Registered psychiatric nurses 20% 30-34 years old 39% 1-5 years in nursing 27% Long-term care 52%

Program directors

57% (SD = 0.631)

Prince Edward Island 73% Rural 58% Management 33% Nurse practitioners 78% 50-54 years old 64% 16-20 years in nursing 68% Government sector 55%

Alberta 44% Remote/isolated 46% Support to front-line practitioners 21% Licensed practical nurses 25% 45-49 years old 44% 1-5 years in nursing 27% Long-term care 50%

Nursing managers

83% (SD = 0.370)

Quebec 100% Urban — other 86% Management 89% Nurse practitioners 91% 30-34 years old 94% 16-20 years in nursing 96% Long-term care 83%

Saskatchewan 73% Remote/isolated 69% Front-line or field staff 77% Registered psychiatric nurses 73% 45-49 years old 73% 1-5 years in nursing 55% Government 72%








Front-line nurses

92% (SD = 0.280)

British Columbia 100% Urban — inner city 94% Nurse practitioners 100% Front-line nurses 100% 30-34 years old 94% 6-10 years in nursing 96% Acute care 93%

Saskatchewan 77% Remote/isolated 85% Licensed practical nurses 88% Management 87% 45-49 years old 88% 1-5 years in nursing 73% Government 79%

4. [Staff] Competency considerations are incorporated into model design. (work to full scope of practice, decisions consider multiple levels of experience, level of experience of available staff, etc.)

79% (SD = 0.422)

Prince Edward Island 100% Urban — inner city 78% Academic 83% Registered psychiatric nurses 80% 55-59 years old 88% >20 years in nursing78% Acute care 78%

Quebec 67% Remote/isolated 77% Front-line or field staff 73% Nurse practitioners 74% 30-34 years old 50% 11-15 years in nursing 62% Government 72%

5. The nursing care delivery model is responsive to clients. (supports continuity of care, supports continuity of caregiver, actively involves clients and families, etc.)

88% (SD = 0.324)

New Brunswick 95% Rural 86% Nurse practitioners 91% Management 82% 35-39 years old 100% 1-5 years in nursing 91% Community health 85%

Saskatchewan 77% Urban — other 76% Licensed practical nurses 50% Front-line nurses 81% 30-34 years old 61% 6-10 years in nursing 67% Long-term care 72%








6. The organizational structure supports the nursing care delivery model. (considers health human resources, contributes to positive organizational climate, supports collaboration, etc.)

81% (SD = 0.408) New Brunswick 95% Remote/isolated 92% Academic 74% Nurse practitioners 91% 55-59 years old 86% >20 years in nursing 79% Government 82%

Saskatchewan 59% Urban — inner city 74% Front-line or field staff & Support to front-line

practitioners 74% Registered psychiatric nurses 53% 35-39 years old 62% 1-5 years in nursing 64% Acute care 74%

7. Nursing care delivery models are designed to contribute to long-term sustainability of the health-care system. (cost-effective, consider staff expertise when assessing cost-effectiveness, consider collaboration when assessing cost-effectiveness, etc.)

68% (SD = 0.554) Prince Edward Island 87% Remote/isolated 92% Management 66% Nurse practitioners 70% 40-44 years old 71% 1-5 years in nursing 91% Government 79%

British Columbia 43% Urban — other 57% Support to front-line practitioners 61% Registered psychiatric nurses 47% 30-34 year old 44% 6-10 years in nursing 56% Long-term care 59%

8. Staff mix decisions, as a component of a nursing care delivery model, are based on client care needs. (complexity, predictability, acuity, etc.)

82% (SD = 0.386)

Prince Edward Island and Quebec 100% Rural 80% Registered psychiatric nurses 87% Management 82% 55-59 years old 90% >20 years in nursing 83% Acute care 83%

Saskatchewan 64% Remote/isolated 62% Licensed practical nurses 63% Academic 74% 35-39 years old 62% 11-15 years in nursing 57% Community health 75%








9. Nursing care delivery models reflect the context of care. (local geography, physical environment, practice sector, client population, etc.)

61% (SD = 0.578)

Newfoundland and Labrador 70% Remote/isolated 77% Academic 63% Licensed practical nurses 75% 60+ years old 74% >20 years in nursing 64% Community health 69%

Yukon 42% Urban — other 49% Support to front-line practitioners 47% Registered psychiatric nurses 47% 30-34 years old 33% 16-20 years in nursing 32% Long-term care 54%

10. The nursing care delivery model optimizes use of human resources. (turnover, overtime, vacancies, etc.)

75% (SD = 0.475) New Brunswick 95% Urban — other 78% Academic 74% Nurse practitioners 74% 60+ years old 82% >20 years in nursing 75% Acute care 74%

Saskatchewan 59% Rural 68% Support to front-line practitioners 65% Licensed practical nurses 50% 30-34 years old 61% 11-15 years in nursing 62% Long-term care 67%

11. Staff mix within nursing care delivery models is compliant with sector requirements. (legislation, professional standards, best practice guidelines, etc.)

62% (SD = 0.525)

Prince Edward Island 93% Remote/isolated 69% Management 64% Nurse practitioners 61% 35-39 years old 69% >20 years in nursing 63% Government 66%

Yukon 43% Urban — other 54% Front-line or field staff 52% Registered psychiatric nurses 53% 30-34 years old 39% 6-10 years in nursing 44% Acute care 58%








12. A formal plan guides decisions about the implementation of nursing care delivery models. (risks/benefits to clients/staff; compatibility with organization’s vision and mission, etc.)

62% (SD = 0.537)

Quebec 83% Urban — inner city 60% Management 61% Nurse practitioners 70% 55-59 years old 74% >20 years in nursing 64% Community health 63%

Yukon 29% Remote/isolated 54% Support to front-line practitioners 50% Registered psychiatric nurses 33% 30-34 years old 28% 16-20 years in nursing 41% Government 52%

13. Technology facilitates implementation of the nursing care delivery model. (electronic health record, personal digital assistants, computers, etc.)

47% (SD = 0.576)

Quebec 83% Remote/isolated 54% Academic 49% Licensed practical nurses 50% 50-54 years old 50% 1-5 years in nursing 55% Community health 48%

British Columbia 24% Rural 42% Support to front-line practitioners 37% Registered psychiatric nurses 27% 40-44 years old 35% 16-20 years in nursing 24% Long-term care 35%

14. Clinical and management decision-making is evidence-based. (keep staff up to date, alignment for building nursing workforce, base staff mix on best evidence related to quality care and client outcomes, etc.)

77% (SD = 0.455)

Prince Edward Island 87% Remote/isolated 92% Front-line or field staff 76% Licensed practical nurses 75% 55-59 years old 81% 1-5 years in nursing 91% Government 86%

Yukon 57% Urban — inner city 70% Support to front-line practitioners 65% Registered psychiatric nurses 53% 45-49 years old 58% 16-20 years in nursing 59% Acute care 72%








15. The care delivery model incorporates the elements of a professional practice environment. (orientation, professional development, training to work collaboratively, etc.)

69% (SD = 0.492)

New Brunswick 76% Rural 68% Academic 74% Nurse practitioners 75% 55-59 years old 74% >20 years in nursing 70% Long-term care 70%

Yukon 57% Remote/isolated 46% Front-line or field staff 60% Licensed practical nurses 50% 30-34 years old 39% 16-20 years in nursing 47% Government 52%

16. A corporate communication plan about the implementation of the model is established. (information for managers, front-line staff, and public, etc.)

61% (SD = 0.572)

Quebec 83% Remote/isolated 69% Management 61% Registered nurses 60% 25-29 years old 75% >20 years in nursing 61% Government 76%

British Columbia 38% Rural 58% Front-line or field staff 49% Registered psychiatric nurses 40% 35-39 years old 31% 11-15 years in nursing 48% Long-term care 50%

17. Leadership across all levels of the organization supports the nursing care delivery model including staff-mix decisions. (awareness, knowledgeable, involved in changes, etc.)

76% (SD = 0.480)

Quebec 100% Urban — other 77% Support to front-line practitioners 74% Licensed practical nurses 75% 55-59 years old 82% >20 years in nursing 76% Government 83%

Yukon 57% Remote/isolated 69% Management 72% Registered psychiatric nurses 67% 30-34 years old 61% 1-5 years in nursing 45% Acute care 72%








18. A structured evaluation assesses the nursing care delivery model planning, design, implementation and outcome identification. (feedback on performance, evaluation of staff mix, monitor nurse-sensitive indicators, etc.)

73% (SD = 0.451)

New Brunswick 90% Remote/isolated 85% Management 74% Registered nurses 71% 55-59 years old 84% >20 years in nursing 75% Community health 74%

British Columbia 57% Urban — other 67% Support to front-line practitioners 66% Nurse practitioners 26% 30-34 years old 50% 16-20 years in nursing 56% Acute care 66%


Appendix C: Results of Delphi 2

Table C.1: Delphi 2 ranking of 10 consolidated principles (completed and incomplete surveys combined)

Principles

Average weighted score

(maximum of 4)

Percentage of total responses

for which a top ranking was given

Percentage of total

respondents that ranked

the principle in the top 4

Highest and lowest percentage response of very important by province or territory, geographic type, role description, professional designation, age, years in nursing and health-care sector (not weighted)

Results not included for five or fewer respondents in a category or for “other.”

Some respondents reported more than one category for geographic type (i.e., urban or rural), professional designation and health-care sector.


Responding to the health-care needs of clients, families and communities is integral to the nursing care delivery model.

2.81 34% 59%

Saskatchewan 86% Rural 64% Front-line or field staff 62% Licensed practical nurses 66% <25 years old 66% 1-5 years in nursing 66% Community health 64%

Newfoundland and Labrador 45% Urban — inner city 55% Management 50% Registered psychiatric nurses 15% 45-49 years old 48% <1 year in nursing 52% Government 55%

Staff competencies (knowledge, skills, abilities, attitudes) are a part of the nursing care delivery model.

2.73 29% 65%

Saskatchewan 72% Urban — inner city 69% Front-line or field staff 69% Licensed practical nurses 74% <25 years old 78% 6-10 years in nursing 75% Acute care 67%

Nova Scotia 58% Urban — other 61% Support to front-line practitioners 57% Nurse practitioners 60% 60+ years old 61% 11-15 years in nursing 56% Government 53%

The nursing care delivery model reflects an organization’s client population, best practices, professional standards and research evidence. 2.68 30% 52%

Prince Edward Island 69% Urban — other 57% Academic 65% Nurse practitioners 63% 40-44 years old 58% 11-15 years in nursing 57% Government 74%

Alberta 40% Remote/isolated 46% Front-line or field staff 50% Unregulated care providers 8% <25 years old 32% 1-5 years in nursing 48% Long-term care 48%



Principles


(maximum of 4)



Percentage of total







Front-line nursing staff and nursing management are engaged in decision-making about the nursing care delivery model.

2.61 30% 65%

Prince Edward Island 85% Urban — inner city 63% Academic 58% Registered psychiatric nurses 74% <25 years old 70% 6-10 years in nursing 73% Acute care 67%

New Brunswick 57% Remote/isolated 71% Front-line or field staff 67% Nurse practitioners 59% 55-59 years old 59% <1 year in nursing 59% Government 47%

The nursing care delivery model promotes quality and safe care, which is cost-effective and sustains the system.

2.60 27% 44%

Prince Edward Island 54% Urban — other 47% Management 54% Nurse practitioners 48% <25 years old 49% <1 year in nursing 52% Long-term care 47%

Alberta 42% Rural 41% Front-line or field staff 43% Licensed practical nurses 41% 25-29 years old 38% 6-10 years in nursing 37% Government 32%

Systematically collected data about client outcomes and nursing human resources inform decisions about the nursing care delivery model.

2.27 19% 17%

Prince Edward Island 54% Urban — inner city 21% Academic 26% Registered nurses 19% 45-49 years old 23% <1 year in nursing 24% Government 32%

Newfoundland and Labrador 14% Remote/isolated 15% Front-line or field staff 15% Nurse practitioners 13% 50-54 years old 13% 11-15 years in nursing 12% Long-term care 14%



Principles


(maximum of 4)



Percentage of total







A formal plan for the nursing care delivery model, including communication and educational strategies, considers client and staff needs as well as the organizational mission.

2.20 18% 34%

Quebec 67% Urban — inner city 37% Support to front-line 36% Licensed practical nurses 42% 25-29 years old 37% 16-20 years in nursing 37% Government 43%

Nova Scotia 24% Remote/isolated 33% Academic 31% Registered psychiatric nurses 27% 30-34 years old 28% >20 years in nursing 33% Community health 33%

Organizational structure and leadership across all levels support the nursing care delivery model.

1.98 11% 24%

Saskatchewan 31% Rural 26% Support to front-line practitioners 33% Nurse practitioners 33% <25 years old 34% <1 year in nursing 31% Acute care 25%

British Columbia 15% Remote/isolated 22% Front-line or field staff 23% Registered nurses 24% 40-44 years old 19% 11-15 years in nursing 22% Government 15%

Staff mix based on client care needs is a component of the nursing care delivery model.

1.89 6% 30%

Saskatchewan 35% Remote/isolated 44% Management 31% Licensed practical nurses 33% 45-49 years old 31% 11-15 years in nursing 29% Government 40%

Nova Scotia 32% Urban — inner city 25% Academic 23% Nurse practitioners 24% 30-34 years old 19% <1 year in nursing 21% Community health 25%



Principles


(maximum of 4)



Percentage of total







Technology is a required component for implementing the nursing care delivery model.

1.49 1% 12%

Manitoba 14% Rural 14% Management 14% Nurse practitioners 16% 50-54 years old 16% 11-15 years in nursing 13% Community health 12%

Ontario 13% Urban — other 11% Academic 10% Licensed practical nurses 10% 25-29 years old 6% 6-10 years in nursing 8% Acute care 12%


Table C.2: Delphi 2 results: In your opinion how would you describe each principle below using the following definitions?

Design principle Implementation/

evaluation principle Both design and

implementation/evaluation principle

(i) Systematically collected data about client outcomes and nursing human resources inform decisions about the nursing care delivery model.

553 (29%) 419 (22%) 951 (49%)

(ii) Front-line nursing staff and nursing management are engaged in decision-making about the nursing care delivery model.

475 (25%) 483 (25%) 965 (50%)

(iii) Staff competencies (knowledge, skills, abilities, attitudes) are incorporated into the nursing care delivery model.

534 (28%) 490 (25%) 899 (47%)

(iv) Responding to the health-care needs of clients, families and communities is integral to the nursing care delivery model.

435 (23%) 439 (23%) 1,049 (55%)

(v) Staff mix based on client care needs is a component of the nursing care delivery model.

646 (34%) 456 (24%) 821 (43%)

(vi) Organizational structure and leadership across all levels support the nursing care delivery model.

683 (36%) 330 (17%) 910 (47%)

(vii) Technology is a required component for implementing the nursing care delivery model.

583 (30%) 492 (26%) 848 (44%)

(viii) The nursing care delivery model promotes quality and safe care, which is cost-effective and sustains the system.

445 (23%) 347 (18%) 1,131 (59%)

(ix) The nursing care delivery model reflects an organization’s client population, best practices, professional standards and research evidence.

552 (29%) 240 (12%) 1,131 (59%)

(x) A formal plan for the nursing care delivery model, including communication and educational strategies, considers client and staff needs as well as the organizational mission.

533 (28%) 281 (15%) 1,109 (58%)


Appendix D: Randomly Ordered List of 10 Principles as Presented in Delphi 2 Survey

i. Systematically collected data about client outcomes and nursing human resources inform decisions about the nursing care delivery model.

ii. Front-line nursing staff and nursing management are engaged in decision-making about the nursing care delivery model.

iii. Staff competencies (knowledge, skills, abilities, attitudes) are a part of the nursing care delivery model.

iv. Responding to the health-care needs of clients, families and communities is integral to the nursing care delivery model.

v. Staff mix based on client care needs is a component of the nursing care delivery model.

vi. Organizational structure and leadership across all levels support the nursing care delivery model.

vii. Technology is a required component for implementing the nursing care delivery model.

viii. The nursing care delivery model promotes quality and safe care, which is cost-effective and sustains the system.

ix. The nursing care delivery model reflects an organization’s client population, best practices, professional standards and research evidence.

x. A formal plan for the nursing care delivery model, including communication and educational strategies, considers client and staff needs as well as the organizational mission.


References

Canadian Institute for Health Information. (2010a). Regulated nurses: Canadian trends, 2005 to 2009.

Ottawa: Author. Retrieved from http://secure.cihi.ca/cihiweb/products/nursing_report_2005-2009_en.pdf

Canadian Institute of Health Information. (2010b, December 9). Canada’s nursing workforce grows

9% in five years. [News release]. Retrieved from http://www.cihi.ca/cihi-ext-portal/internet/en/ document/spending+and+health+workforce/workforce/nurses/release_09dec2010

Canadian Nurses Association, Canadian Council for Practical Nurse Regulators, Canadian Practical Nurses Association, & Registered Psychiatric Nurses of Canada. (2005). Evaluation framework to determine the impact of nursing staff mix decisions. Ottawa: Canadian Nurses Association. Retrieved from www.cna-aiic.ca

Canadian Nurses Association. (2011). Invitational round table — nursing care delivery models and staff mix: Using evidence in decision-making. Ottawa: Author. Retrieved from www.cna-aiic.ca

Hsu, C-C., & Sandford, B. A., (2007, August). The Delphi technique: Making sense of consensus. Practical Assessment, Research & Evaluation, 12 (10), 1-8.

Institute of Cultural Affairs. (1998). Facilitation skills: An introduction to group facilitation. Toronto: Author.

Jost, S., Bonnell, M., Chacko, S., & Parkinson, D. (2010, July-September). Integrated primary nursing: A care delivery model for the 21st-century knowledge worker. Nursing Administration Quarterly, 34(3), 208-216.

Registered Nurses’ Association of Ontario. (2007). Healthy work environments best practice guidelines: Professionalism in nursing. Toronto: Author. Retrieved from

http://www.rnao.org/Storage/28/2303_BPG_Professionalism.pdf

Documents

Nursing Care Delivery Models: Canadian …/media/cna/page-content/pdf-en/nursing...Nursing Care Delivery Models: Canadian Consensus on Guiding Principles cna-aiic.ca