Abstract
-
Purpose
This study compares burnout, accountability, nursing competency, and quality of nursing services among nurses through the nursing care models and work experience.
-
Methods
A cross-sectional study was conducted on 129 nurses working for more than six consecutive months in a tertiary hospital in South Korea. Data were collected in August 2023 using the Shirom-Melamed Burnout Questionnaire, Specht and Ramler Accountability Index, Nurse Competence Scale, and Good Nurse Care Scale. Differences between nursing care models were analyzed using an independent t-test.
-
Results
Nurses in the team nursing method demonstrated lower levels of burnout and higher levels of accountability, nursing competency, and quality of nursing services than those in the functional nursing method. All differences were statistically significant, except for accountability. Novice and advanced beginner nurses showed statistically significant differences in burnout; competent and proficient nurses showed statistically significant differences in accountability, nursing competency, and quality of nursing services, excluding burnout; and expert nurses showed no statistically significant differences in nursing performance by nursing care model.
-
Conclusion
The team nursing method showed better results in addressing nurses’ burnout, accountability, nursing competency, and quality of nursing services. The team nursing methods meet the needs of nurses seeking the total care of patients.
-
Key Words: Team nursing; Caregiver burden; Social responsibility; Clinical competence; Nursing services
INTRODUCTION
The nursing care model is a framework that creates and designs nursing services according to the characteristics of the hospital and nursing unit [
1]. It assigns activities to nurses and allows them to choose and adopt a philosophy of care [
2]. The nursing care model has evolved from the total patient care nursing or individual method to the functional nursing method, team nursing method, and lastly, the primary nursing method. These four methods have been dominantly utilized in acute hospitals [
2]. Subsequently, a modified approach to team nursing method, modular nursing, was developed [
3]. An adapted model called the primary team model, which combines elements of both team nursing and primary nursing methods, was also implemented [
4]. Therefore, even models of similar names can be operated in different ways [
5]. The nursing care model is divided into task-oriented and person-centered approaches. Functional nursing method, a typical task-oriented approach, assigns nurses specific tasks rather than patients. It allows tasks to be completed in a shorter time but may lead to fragmented care and reduce nurses' responsibilities. On the other hand, person-centered team nursing method is a model in which a team leader, who has knowledge of the patient and is responsible for evaluating the patient's treatment plan, leads the team. The leader assigns patients to team members who are responsible for their treatment and outcomes [
2-
5]. Some studies [
6] have suggested that different nursing care models do not show a substantial difference in quality, cost, and satisfaction. Most nurses prefer a person-centered nursing care model rather than a task-centered functional nursing method [
2]. The rationale for choosing different care models ranges from economic considerations to staff availability [
5].
The functional nursing and team nursing methods are the nursing care models most adopted in Korean hospitals [
7]. Nursing administrators have traditionally considered the functional nursing method as an economical and efficient approach to the shortage of nurses [
8]. Additionally, the functional nursing method has advantages such as ease of application for new nurses and the potential to maximize task efficiency [
8]. However, as nurses gain more experience, this fragmented approach can lead to decreased job satisfaction, low-quality nursing services, and patient dissatisfaction [
6]. Nursing care models affect nurses’ care activities, authority, and accountability [
1,
2] and impact nursing performance. They are associated with nurses’ burnout [
9] and correlated with a decline in nursing quality, ultimately affecting patients’ health [
10]. Therefore, nursing administrators must choose an appropriate nursing care model that can meet the needs of the organization and patients [
11].
In response to these demands for change, a tertiary hospital in South Korea has been making efforts to transition from the functional nursing method to the team nursing method since 2016. Furthermore, the advantages and disadvantages of each nursing care model have not been sufficiently researched [
5,
6]. Thus this study aims to compare nursing performance factors, such as burnout, accountability, nursing competency, and quality of nursing services, through six nursing units operating under functional and team nursing methods. This study aims to provide foundational data to establish an appropriate nursing care model based on the characteristics of nurses working in units implementing functional and team nursing methods.
METHODS
Study Design and Participants
This cross-sectional study compared the differences in burnout, accountability, nursing competency, and quality of nursing services of nursing staff under the functional nursing and team nursing methods. This study targeted six wards within a tertiary hospital in South Korea undergoing a transformation in its nursing care model. The hospital primarily employed the functional nursing method as its main nursing care model in all 21 nursing units. However, owing to the different characteristics of each nursing unit, as of August 2023, six wards had already converted to the team nursing method since 2016. Among these, we selected three units—one each from the medical, surgical, and other categories—where the transition to the team nursing system has taken more than a year. We also chose three wards using the functional nursing method with similar bed sizes and patient characteristics, taking into account the characteristics of the three selected team nursing units.
Participants were nursing staff working for six months or more in the six wards as of August 2023 [
12]. A total of 129 out of 145 nurses participated in the study; a total of 13 new nurses with less than 6 months of experience, 2 who did not agree to participate, and 1 on a long-term leave were excluded.
To measure nurses’ burnout, accountability, nursing competency, and quality of nursing services, data were collected from August 1 to 15, 2023, under our supervision. All four instruments used in this study underwent the following procedures. First, approval for their use was obtained from the instrument developer or their representative. The authors then independently translated the instruments into Korean and refined them through a comparative adjustment process. To ensure content validity, six individuals–including two nursing professors and four nursing researchers–reviewed the translations. Subsequently, pilot studies were conducted with 15 research participants. The participants were asked to provide feedback on their understanding of the translated content—including typographical errors and issues related to terminology—to ensure that the translated version could be used accurately and without error. Based on this feedback, the final version was confirmed.
Burnout
Burnout is a common psychological phenomenon among nurses [
13]; it is a mental condition caused by continuous and long-term stress exposure, particularly related to psychosocial factors at work [
14]. We measured burnout using the Shirom-Melamed Burnout Questionnaire, compromising 22 items across 4 subscales—Physical Fatigue, Cognitive weariness, Tension, and Listlessness [
15]—where a lower score indicates lower levels of burnout. The reliability of this tool in the original study was Cronbach's α of .84 [
15]; Gerber et al. [
16] reported .820, and in this study, Cronbach's α was .890.
Accountability
No agreed-upon definition of accountability exists [
17]. However, Maas [
18] defines individual accountability as the individual nurse’s answerability, for the outcomes of their actions, to patients, peers, and the organization. Hochwarter et al. [
19] define it as an individual’s perceived level of answerability. We measured accountability with the 23-item Specht and Ramler Accountability Index, which consists of two subscales: individual referent and group referent [
20]. The scores are averaged, with high scores indicating high levels of perceived accountability. The Cronbach’s alpha for the individual referent ranged from .40 to .74 [
20]; Sorensen et al. [
21] reported with a Cronbach’s α of .820, in our study, it was .890.
Nursing competency
Nursing competency is defined as the ability to perform a task with desirable outcomes [
22], the effective application of knowledge and skills, and something that an individual is capable [
23]. Nakayama et al. [
24] define nursing competency as the ability to act by combining the knowledge, skills, values, beliefs, and experiences acquired as a nurse. We measured it using the Nurse Competence Scale developed by Meretoja et al. [
25], a 73-item scale divided into seven categories: helping role (7 items), teaching–coaching (16 items), diagnostic functions (7 items), managing situations (8 items), therapeutic interventions (10 items), ensuring quality (6 items), and work role (19 items). Each item is rated using visual analog scale (0–100), with the ends labeled 0 and 100 for a considerably low and high level of competence, respectively. Meretoja et al. [
25] reported the reliability of the Nurse Competence Scale with a Cronbach’s α ranging from .790 to .910, while, in the present study, Cronbach’s α was .983.
Quality of nursing services
Quality is a multidimensional issue involving various features that depend on service performance and personal assessment [
26] and is thus difficult to define; however, nurses – the largest healthcare workforce—play a vital part in assuring quality healthcare [
27]. We defined the quality of nursing services as the concept of good nursing [
28] and measured it using the Good Nursing Care Scale [
29], which consists of seven 46-item subscales. The higher the score, the higher the quality of nursing services. In addition, nursing quality scores of 1.0–1.5 indicate considerably low quality of care; 1.6–2.0 indicates low quality; 2.1–2.5 indicates fairly low quality; 2.6–3.0 indicates fairly high quality; 3.1–3.5 indicates high quality; and 3.6–4.0 indicates considerably high quality, which was considered a sufficient level. In Stolt et al.’s study [
28], the reliability of the Good Nursing Care Scale was Cronbach’s α .880, while in the present study, Cronbach’s α was .966.
We performed data analysis using the IBM SPSS Statistics ver. 27.0 for Windows program. The general characteristics of the subjects were analyzed by frequency and percentage, mean and standard deviation, and the normality test of the dependent variable was analyzed by the Shapiro-Wilk test. The homogeneity test for the general characteristics and dependent variables was analyzed using an independent t-test and a chi-square test. The burnout of nurses, responsibility and nursing competency, and quality of nursing service were presented by mean and standard deviation, and the difference in effect by the nursing delivery system and nursing career was analyzed by Mann-Whitney U-test or independent t-test according to the results of the normality test. Also, referring to Benner’s theory [
30] we classified nursing careers as follows: those with 1–3 years of experience as novice and advanced beginner nurses; those with 4–11 years as competent and proficient nurses; and those with more than 12 years as expert nurses. The effect size of the nursing delivery system by nursing career was estimated by calculating Cohen’s d.
The design of this study was approved by the Institutional Review Board of Soonchunhyang University Bucheon Hospital (No. 2020-11-014-008). Participants were informed about the research purpose, methods, confidentiality, and anonymity of their data. Written informed consent was obtained from each participant before the survey and collected. We distributed and collected questionnaires using sealed envelopes.
RESULTS
General Characteristics of the Participants
A total of 129 nurses participated; 48 in the functional nursing method and 81 in the team nursing method (
Table 1). Of the participants, 98.8% were women with an average age of 30.8±6.6 years, and the majority (70.5%) were single. Furthermore, 82.2% of participants had a bachelor’s degree in nursing. The average working experience at the hospital was 7.76±6.84 years, and the average working experience at the ward was 3.24±2.34 years. Of all nurses, 9.3% were novice nurses with less than 1 year of experience; 22.5% were advanced beginner nurses; 29.5% were competent nurses; 11.6% were proficient nurses, and 27.1% were expert nurses. We observed no statistically significant difference in participants’ characteristics between the functional nursing and team nursing methods.
Findings show that nurses’ burnout was lower in the team nursing method than in the functional nursing method; responsibility, nursing competency, and quality of nursing service showed higher scores, and all were statistically significant except for accountability (
Table 2). Nurse burnout was 3.24±0.52 and 3.03±0.54 in the functional nursing and team nursing methods (t=2.19,
p=.030), respectively. Nurse accountability was 3.07±0.37 in the functional nursing method and 3.20±0.36 in the team nursing method (z=-1.42,
p=.157), and nursing competency was 64.44±16.54 and 74.46±13.61 in the functional nursing and team nursing method (z=-3.40,
p<.001), respectively. The quality of nursing services was 2.91±0.43 in the functional nursing method and 3.21±0.47 in the team nursing method (z=-3.49,
p<.001).
Results revealed significant differences between the functional nursing and team nursing methods. Novice and advanced beginner nurses exhibited statistically significant differences in burn out, while competent and proficient nurses showed differences in accountability, nursing competency, and the quality of nursing services, excluding burnout. But we found no significant differences in nursing delivery systems among expert nurses (
Table 3).
For novice and advanced beginner nurses, we found no statistically significant difference between the functional nursing and team nursing methods for accountability, nursing competency, and quality of nursing service. However, the functional nursing and team nursing methods scored 3.35±0.47 and 2.99±0.52, respectively, for burn out. Therefore, nurses in the functional nursing methods perceived their burnout to be higher (t=-2.19, p=.034) than those in the team nursing method.
For competent and proficient nurses, accountability was significantly higher in the team nursing method (3.25±0.35) than in the functional nursing method (2.84±0.39; t=-3.71, p<.001). Additionally, nursing competency scores were higher in the team nursing method (75.72±11.77) than in the functional nursing method (60.56±17.32; t=-3.20, p=.001). Furthermore, in the quality of nursing services, the team nursing method (3.26±0.50) scored higher than the functional nursing method (2.64±0.35; t=-4.60, p<.001).
DISCUSSION
Few studies have examined the associations between nurse staffing and nursing care models concerning nursing services [
5]. To our knowledge, this study is the first to compare nursing performance in functional nursing and team nursing methods from the perspective of nurses. It shows that the team nursing method is associated with low nurse burnout and high accountability, nursing competency, and quality of nursing services compared to the functional nursing method. Therefore, a person-centered approach demonstrated better nursing performance than a task-centered one.
As professionals who help people, nurses are at a considerably high risk of burnout due to constant exposure to emotional tension and stressful work environments [
31]. When nurses experience a high level of burnout, it becomes challenging for them to perform nursing tasks effectively [
32]. Burnout scores were higher in the functional nursing method. Although no difference in cognitive weariness or physical fatigue by the nursing care model was found, listlessness and tension were significantly higher in the functional nursing method. This is interpreted as a problem experienced by nurses in functional nursing wards, as they repeatedly perform only specific tasks assigned to them and do not have comprehensive information about the patients [
2]. Substantial evidence has linked simple repetitive tasks with fatigue [
33].
Accountability is essential in nursing because a significant correlation exists between accountability and autonomy, and a nurse’s accountability is an important predictor of job satisfaction [
20,
34]. We observed no significant difference in nurse accountability by nursing care model as measured by the Specht and Ramler Accountability Index. This finding aligns with Boni’s study [
34], which also utilized the same assessment tool to compare nurses’ accountability. Although the compared nursing care models (team nursing, primary nursing, patient-focused care modular) were different, we found no statistically significant difference in nurses’ accountability for each nursing care model (
p<.05).
Nursing competency is a combination of elements, including knowledge, skills, professional attitudes, critical thinking, and values required in specific situations [
35,
36]. Nurses’ competency showed significant differences between the functional nursing and team nursing methods. Across all seven subscales, the competency score of the team nursing method was, on average, 10 points higher than that of the functional nursing method. Therefore, compared to the functional nursing method, the team nursing method provides an environment in which nurses can better demonstrate their capabilities.
Nurses, the largest healthcare workforce, play a vital part in assuring quality healthcare [
27]. We assessed the quality of nursing using the Good Nursing Care Scale. Nurses’ perceived quality of nursing service was significantly higher in the team nursing method than in the functional nursing method across all six subscales, excluding cooperation with relatives. Furthermore, the Good Nursing Care Scale categorizes the quality of nursing service into six grades. While the functional nursing method falls within the “fairly high” category with an average score of 2.6–3.0, the team nursing method is classified as “high” with an average score of 3.1–3.5, indicating a nursing service of one grade higher quality. Although it was not a study using the same tool, Arifin et al.’s study [
37], comparing functional and team nursing methods also reported that the quality of nursing service was more effective in the team nursing method. This comparison was not made across nursing care models; however, clear evidence suggests that the quality of nursing service is influenced by the work environment [
38].
According to Benner’s from novice to expert [
30], nurses’ clinical competency develop in stages over time. Therefore, based on Benner’s theory, we classified nurses into three stages by work experience. Surprisingly, we only found significant differences among competent and proficient nurses. They have 4–11 years of work experience and were accounted for approximately half of nurses in the units. Competent and proficient nurses in the team nursing method group scored significantly higher in all items except for burnout, and a difference in accountability was also observed. We observed no difference in nursing performance by nursing care model among expert nurses. The differences observed among competent nurses in the team nursing model may suggest a potential influence of work experience; however, further research is needed to confirm and generalize these findings.
Findings on the relationship between work duration and burnout have varied. Meltzer and Huckabay [
39] reported that burnout increases with longer work duration. However, the overall assessment of the relationship between burnout and work duration did not demonstrate any statistical significance; thus, the relationship between the two is nonlinear [
40]. Burnout showed no significant differences by work duration across nursing care models. However, novice and advanced beginner nurses had the highest burnout scores in the functional nursing method and the lowest scores in team nursing method. Although it is difficult to find research on the relationship between accountability and work experience, research on nurses’ work experiences and capabilities has been reported. In general, as work experience increases, nurses’ clinical competencies should also increase, but other studies have shown contrary evidence. In some studies [
41,
42], no significant relationship was found between nurses’ work experience and competency.
Therefore, the above results indicate that to enhance nursing performance, restructuring and designing nursing tasks through the framework of nursing handover systems, which involves environmental changes, should be emphasized. Furthermore, the changes can be led by competent nurses who can work most actively in the nursing unit. This perspective suggests that the task-oriented functional nursing method cannot meet the needs of nurses seeking comprehensive patient care. This finding can be used as basic data for establishing policies related to nursing care models.
This study also had limitations. As mentioned before, nursing care models of similar names may be implemented differently. The team nursing method in this study may differ from practices in other countries or hospitals. Furthermore, nursing experience was classified on years of service only according to Benner’s theory, different from the concept of a career ladder system. Moreover, this study had methodological limitations as it was an observational study.
CONCLUSION
We have developed various nursing care models to overcome environmental constraints and provide high-quality nursing services to patients; therefore, it is difficult to assert that a particular nursing care model is the most effective. The functional nursing method had a significant advantage in maximizing tasks with limited nursing staff. However, in the present era that demands total care, this method struggles to appropriately meet patients’ needs. The team nursing method enables nurses to utilize their nursing competencies more effectively, thereby enhancing the quality of nursing services and fostering an environment where nurses can work with a sense of accountability. This research will serve as foundational data for selecting an appropriate model that improves the quality of nursing services.
Article Information
-
Author contributions
Conceptualization: SKP, SHP. Formal analysis: SHP. Data curation: SKP. Funding acquisition: SHP. Writing - original draft: SHP. Writing - review & editing: SKP, SHP. All authors read and agreed to the published version of the manuscript.
-
Conflict of interest
None.
-
Funding
This work was supported by the Soonchunhyang University Research Fund.
-
Data availability
Please contact the corresponding author for data availability.
-
Acknowledgments
None.
Table 1.General Characteristics of Participants (N=129)
|
Variable |
Category |
n (%) or M±SD |
X2 or t |
p
|
|
Total (n=129) |
Functional nursing method (n=48) |
Team nursing method (n=81) |
|
Gender |
Woman |
128 (99.2) |
48 (100.0) |
80 (98.8) |
0.56 |
.440 |
|
Man |
1 (0.8) |
- |
1 (1.2) |
|
|
|
Age (yr) |
|
30.8±6.6 |
30.8±6.5 |
30.8±6.8 |
0.03 |
.975 |
|
Marital status |
Single |
91 (70.5) |
32 (66.7) |
59 (72.8) |
0.55 |
.457 |
|
Married |
38 (29.5) |
16 (33.3) |
22 (27.2) |
|
|
|
Education |
Diploma |
20 (15.5) |
7 (14.6) |
13 (16.0) |
0.07 |
.964 |
|
Bachelor |
106 (82.2) |
40 (83.3) |
66 (81.5) |
|
|
|
Master |
3 (2.3) |
1 (2.1) |
2 (2.5) |
|
|
|
Work career in hospital (yr) |
|
7.76±6.84 |
8.31±6.99 |
7.43±6.77 |
0.71 |
.479 |
|
Work career in unit (yr) |
|
3.24±2.34 |
3.31±2.79 |
3.20±2.05 |
0.25 |
.784 |
|
Carrier stage (yr)*
|
≤3 |
41 (31.8) |
16 (33.3) |
25 (30.9) |
3.79 |
.150 |
|
4~11 |
53 (41.1) |
15 (31.3) |
38 (46.9) |
|
|
|
≥12 |
35 (27.1) |
17 (35.4) |
18 (22.2) |
|
|
Table 2.Comparison between Functional Nursing Method and Team Nursing Method (N=129)
|
Variable |
M±SD |
t or z |
p
|
|
Functional nursing method (n=48) |
Team nursing method (n=81) |
|
Burn out (total) |
3.24±0.52 |
3.03±0.54 |
2.19 |
.030 |
|
Cognitive weariness |
2.67±0.78 |
2.44±0.76 |
-1.96 |
.051 |
|
Physical fatigue |
3.57±0.60 |
3.43±0.67 |
1.22 |
.224 |
|
Listlessness |
3.25±0.52 |
3.04±0.54 |
2.12 |
.036 |
|
Tension |
3.44±0.69 |
3.12±0.65 |
2.62 |
.010 |
|
Accountability (total) |
3.07±0.37 |
3.20±0.36 |
-1.42 |
.157 |
|
Individual referent |
3.08±0.32 |
3.18±0.38 |
-1.45 |
.149 |
|
Collective |
3.06±0.49 |
3.21±0.41 |
-1.43 |
.154 |
|
Competency (total) |
64.44±16.54 |
74.46±13.61 |
-3.40 |
<.001 |
|
Helping role |
63.91±17.74 |
75.12±11.74 |
-3.85 |
<.001 |
|
Teaching-coaching |
67.70±18.75 |
75.62±13.80 |
-2.35 |
.019 |
|
Diagnostic functions |
66.95±17.41 |
76.43±14.87 |
-3.22 |
.001 |
|
Managing situations |
71.84±16.60 |
81.24±12.77 |
-3.52 |
<.001 |
|
Therapeutic interventions |
56.97±21.71 |
69.17±20.68 |
-3.31 |
<.001 |
|
Ensuring quality |
50.99±25.65 |
67.48±21.99 |
-3.81 |
<.001 |
|
Work role |
66.02±17.94 |
74.65±16.31 |
-2.84 |
.004 |
|
Quality of nursing care (total) |
2.91±0.43 |
3.21±0.47 |
-3.49 |
<.001 |
|
Nursing staff characteristics |
3.04±0.60 |
3.41±0.55 |
<.001 |
<.001 |
|
Care related activities |
3.13±0.57 |
3.44±0.50 |
-3.07 |
.002 |
|
Preconditions for care |
2.44±0.58 |
2.79±0.56 |
-3.27 |
.001 |
|
Nursing environment |
3.09±0.46 |
3.38±0.51 |
-3.00 |
.003 |
|
Course of the nursing process |
2.71±0.51 |
2.96±0.52 |
-3.07 |
.002 |
|
Patients’ coping strategies |
3.03±0.53 |
3.34±0.60 |
-3.02 |
.003 |
|
Collaboration with relatives |
2.87±0.61 |
3.09±0.76 |
-1.78 |
.075 |
|
Concerns of patients’ care/treatment |
8.99±1.08 |
9.21±0.88 |
-1.33 |
.183 |
Table 3.Comparison of Functional Nursing and Team Nursing Methods by Work Experience (N=129)
|
Variable |
Carrier stage (yr)*
|
M±SD |
t or z |
p
|
Cohen’s d |
|
Functional nursing method (n=48) |
Team nursing method (n=81) |
|
Burn out |
≤3 |
3.35±0.47 |
2.99±0.52 |
2.19 |
.034 |
1.39 |
|
4~11 |
3.31±0.67 |
3.02±0.49 |
1.73 |
.090 |
0.96 |
|
≥12 |
3.09±0.37 |
3.11±0.65 |
-0.15 |
.884 |
0.09 |
|
Accountability |
≤3 |
3.14±0.28 |
3.11±0.39 |
-0.89 |
.376 |
0.20 |
|
4~11 |
2.84±0.39 |
3.25±0.35 |
-3.71 |
<.001 |
3.12 |
|
≥12 |
3.21±0.34 |
3.19±0.34 |
0.12 |
.902 |
0.12 |
|
Competency |
≤3 |
60.34±15.33 |
68.13±14.70 |
-1.63 |
.056 |
0.04 |
|
4~11 |
60.56±17.32 |
75.72±11.77 |
-3.20 |
.001 |
0.08 |
|
≥12 |
71.71±15.28 |
80.59±12.76 |
-1.87 |
.070 |
0.05 |
|
Quality of nursing |
≤3 |
3.05±0.43 |
3.11±0.44 |
-0.44 |
.676 |
0.32 |
|
4~11 |
2.64±0.35 |
3.26±0.47 |
-4.60 |
<.001 |
3.17 |
|
≥12 |
3.02±0.39 |
3.23±0.50 |
-1.43 |
.163 |
1.07 |
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