Care Perceptions in two ICU Nursing Care Delivery Models: A qualitative-comparative approach

Abstract Objective. Analyzed in compared perspective perceptions about nursing care, nurse-patient interaction, and nursing care outcomes in two ICU nursing staff in a high-complexity hospital institution, whose Nursing are Delivery Models (NCDM) are differentiated by the proportion of nurses and nurse assistants (NA) per team and by the assigned tasks and responsibilities. Methods. Particularist ethnography with adaptation to virtual methodologies. It included the sociodemographic characteristics of 19 nurses and 23 NA, 14 semi-structured interviews, review of patients’ clinical records, and a focus group. Coding, categorization, inductive analysis, validation of results with participants were conducted and thematic saturation was achieved. Results. Four themes were identified: i) Professionalized care: a nursing of superior value; ii) senses and feelings of care; iii) nursing workload, generating factors andimpacts; and iv) nursing missed care as concrete expression of the nursing workload. Conclusion. Compared nursing teams perceived nursing care in different ways, since it was experienced based on the assigned responsibilities and the possibilities of interaction with patients. Nursing care in the NCDM of the ICU with prevalence of direct bedside care by nurses with support from NA, it was perceived as holistic, comprehensive, and empathetic; whereas in the ICU with prevalence of delegated care to NA, it was related with administrative leadership and management of the ICU. Regarding the results, the NCDM of the ICU of direct bedside care by nurses showed better performance in patient safety and was closer to the skill level and legal responsibility of the nursing staff.


Introduction
W ithin a global scenario characterized by nursing shortage, hospital institutions face the challenge of developing nursing care delivery models (NCDM) that involve diverse nursing staff qualification levels, guarantee high quality standards, safeness, cost effectiveness, and job satisfaction. (1) The NCDM are ways in which nursing practice can be organized to care for patients, principally in hospital settings. (2) In nursing literature, four classic NCDM are identified: Total Patient Care (TPC), Functional Nursing (FN), Team Nursing (TN), and Primary Nursing Care (PNC). (1) In the TPC model, the nurse is responsible for all patient care during a shift. (2) The FN model consists in the tasks distribution among the nursing staff in function of care complexity, knowledge, and skills required for its execution. (2) The TN model is comprised by personnel with different levels of experience and training, who also share the collective responsibility of care, optimizing skills, qualification, and team work. (3) In the PNC model, a nurse is responsible for coordinating a patient's continuous care throughout the length of stay. (1) Characteristics of work environments, such as the proportion of nursing staff per unit, number of patients assigned, autonomy in decision making, and team work are predictive factors of results of the NCDM. Studies by Zhao et al., (4) and Lake et al., (5) showed inverse correlations between the characteristics of the work environments and omission of nursing care. Other studies have found associations among the composition of nursing staff, poor job satisfaction, (3) intention to switch jobs, (6) and the perception of low quality of care. (7) Teams conformed with a low proportion of nurses, large proportion of nurse assistants, and high nursing workload are associated with increased mortality, (8,9) length of stay, (8,9) readmissions, (9) increase of hospital-acquired infections, and adverse events. (8,10) In contrast, high assignment of nurses has been correlated with mortality reduction and positive perception of the quality of nursing care. (11) Within the context of Colombian hospitals, the NCDM in Intensive Care Units (ICU) incorporate hybridizations of the aforementioned models. Regarding human resources, it must be highlighted that nursing work in Colombia is conducted under precarious working conditions, regional inequalities in the distribution of personnel, and lack of regulations on the functions of nurses -licensed personnel with university formation-, the functions of nursing assistants (NA) -unlicensed personnel with technical training of 2 600 hours-and on the patient-nursing ratio. (12) Regulatory gaps have had repercussions in displacing the work of nurses toward administrative-type actions and supervision of NA, which implies the forced allocation of most care provision to the NA and the conformation of work staff with a low proportion of nurses and a higher proportion of NA, affecting the quality and safety of care. (13) Moreover, in 2019, Colombia was ranked by the Organization for Economic Cooperation and Development as the country with the greatest shortage of nurses, with an indicator of 1.4 nurses per 1000 inhabitants. (14) Some Colombian hospital institutions have been incorporating NCDM that involve a higher proportion of nurses for direct bedside care and a clearer definition between the roles and limits of the skills of nurses and nursing assistants. However, they have little scientific evidence to support their results, an aspect that motivated proposing this research, with potential contribution to the global discussion on professional practice environments that supports nursing autonomy and leadership, quality of care, and patient safety. The aim was to analyze in compared perspective, perceptions about nursing care, nurse-patient interaction, and.nursing care outcomes in two ICU nursing staff in a high-complexity hospital institution, whose NCDM are differentiated by the proportion of nurses and nursing assistants per team and by the assigned tasks and responsibilities.

Type of study.
Interpretative particularistic ethnographic based on Boyle (15) for the description and contextual interpretation of the meanings attributed by the nursing staff to care provided from two NCDM in ICU. Adaptations were made of the field work to the virtual context given the social distancing norms due to the COVID-19 pandemic.
Setting. The research was conducted in two ICUs of a high-complexity Hospital located in Medellín-Colombia, which differ in the proportion of nurses, NA and in the functions assigned to each team. The study denominated as ICU-Nurse Team that with the highest proportion of nurses responsible for patient care and a lower proportion of NA dedicated to comfort functions; and as ICU-Assistants team that with a high proportion of NAs responsible for most of the patient care, and a low proportion of nurses with a large volume of administrative tasks, responsible for supervising NAs and some high-complexity nursing care.
Participants. The research team was made up by professors from Universidad de Antioquia, Universidad Católica de Oriente, Directors of Nursing from the Hospital, and nursing students. Participant inclusion criteria: nursing staff with at least one-year seniority in ICU-Nurses or ICU-Aides, performing bedside patient care functions or care management.
Data collection. Data collection was carried out between June 2020 and May 2021. A virtual sociodemographic characterization survey was applied to 20 nurses and 33 NA, obtaining an 80% response rate. Thereafter, semi-structured interviews were conducted via Google Meet to five NA and nine nurses and a virtual focus group with six nurses and five NA. The observations were complemented with the revision of clinical records to identify differences with respect to functions, clinical records filled out, and completion of the care plan. Data analysis. By following Wolcott, (16) data coding and categorization was performed through inductive processes, bearing in mind the sampling and theoretical saturation. The findings were validated with the participants.
Ethical aspects. The protocol was subjected to evaluation by the Ethics Committee of the university institution responsible for the research and obtained ethical endorsement in July 2019. Four virtual socialization meetings were held with the staff from both ICUs to introduce the study and the potential participants received an informed consent where they manifested their voluntary intention to participate. Also, identities were protected by substituting the names of the participants with alphanumeric codes. Figure 1 presents the four emerging themes in the study stemming from a set of concentric circles from the center to the periphery. The central circle represents the theme of Professionalized care: nursing of superior value, which shows the differential characteristic of the NCDM and the teams compared. The following ring presents the senses and feelings of care, that is, the perception about care for nurses and NA in each of the teams according with the nursing staff: patient ratio and the functions assigned. The third and fourth rings present two categories related with the work environments where teams compared carry out their work: nursing workload, generating factors and impacts, and nursing missed care as concrete expression of the work burden.

Figure 1. Schematic of thematic relations and analysis categories
Characteristics of the participants. Nurses constitute 64% of the staff in the ICU-Nurses and 25% in the ICU-Assistants. The proportion of NA is 36% in the ICU-Nurse team and 75% in the ICU-Assistants team. The mean time of job experience in both ICUs presents great variability, with values between 1 and 25 years for nurses in the ICU-Nurses team; between 1 and 6 years for nurses in the ICU-Assistants team; and between 1 and 25 years for NA in the ICU-Assistants team, indicating high personnel rotation. The NA in the ICU-Nurses team showed the lowest mean in work experience and age, with little variability in both variables, which suggests that majority in this group is quite young and has little work experience (Table 1). The teams in the ICUs compared were comprised by one nurse and six NA for 12-13 beds ( Table 2). The new NCDM was implemented gradually in half the hospital wards, diminishing the proportion of NA and increasing that of nurses 24 hours per day. The ICU-Nurses team established the 1:3 nurse-patient ratio and 1:4 NA-patient ratio and added a daytime coordinator, while the ICU-Assistants team is in the wards where the existing NCDM was not modified, with 1:13 nurse-patient ratio and 1:2 NA-patient ratio.

Theme 3. Nursing workload: generating factors and impacts
Nursing workload was a common characteristic in the ICUs compared. It derives from factors like assignment criteria, number and severity of patients, parallel responsibilities to care, and from the possibility of effective coordination of the work teams. The allocation of patients is made by geographical proximity in both ICUs, without using criteria, like measurement of workload or severity of the patients, which leads to unequal distribution of the most-complex patients among the staff in the ICUs. For the nurses in the ICU-Assistants team, the workload-generating activities in which they spend most of their work time are taking blood cultures, accompanying the medical rounds of 13 patients, and assisting physicians during invasive procedures or during cardiopulmonary resuscitation. Nurses in the ICU-Nurses team consider their caregiving responsibilities to be overwhelming given that compared with the NA in the ICU-Assistants team, they are responsible for more patients and bedside-care functions, like elaborating the care plan: since we started the model, one tries to do things more consciously and tries to do them better, it takes a little longer (E02).
The NA in the ICU-Nurses team consider the assignment of four patients to surpass their capacity to provide the care required, thus, they experience physical and emotional fatigue, stating that they use up half the shift in bathing their patients. The NA in the ICU-Assistants team reported feeling comfortable and without overburden to provide care to their two patients assigned, except for the person who has an additional patient, which produces mental overburden and affectation in the quality of care provided. There are 13 patients, they day you had that odd-patient there was a more mental workload, it is not the same to take care of two than to take care of three. The quality of care is not the same (A04).
The NA and nurses in both ICUs have additional responsibilities that increase the workload like cleaning equipment, counting medications and medical supplies, custody of elements of the service, accompanying the transfer of patients to surgeries or diagnostic exams, and elaborating multiple registries in the clinical chart. The nursing staff arrives earlier than usual to their work day or extend their work day until after the work shift is over to comply with these obligations. Many colleagues ended up leaving the institution two hours later because they had many things to do, especially the system's registry (E04).
Coordination of care among the nursing staff is a determining factor of the increase or decrease of the workload. When the NA in the ICU-Assistants In turn, the NA in the ICU-Assistants team prioritize care of the biological sphere, like administration of medications, aspiration, and sedation. Care mostoften delayed or omitted include feeding, changes of position, and registries in the system and these delays occur when they have to leave the ward to accompany another patient to a procedure or when another patient shows some complication. Awake patients are considered as demanding care, such as feeding: patients that are quite autonomous we have to help them to feed very often and it is very complicated because the feeding of these patients gets delayed while one is doing something else (B24).
In the ICU-Nurses team, missing care is expressed by nurses not being able to comply with the goals proposed in the care plan: If I don't have the time to dedicate the 15 minutes he needs for the breathing incentive, I won't achieve the goal, which was to remove his oxygen (E05). The seriousness of a patient and the follow-up to diagnostic procedures outside the ward are the factors that most generate workload and missed care.
Coordination and continuity of care are generating factors of undone activities for nurses in the ICU-Nurses team. Revision of clinical histories is a frequently delayed activity, and in some cases, when physicians do not communicate their prescription to nurses, these become aware of changes in the management of patients at the end of the shift. With respect to the continuity of care, nurses are assigned different patients during each shift and rarely do they have a chance to give continuity to their goals and interventions. There is also no continuity for the care plan among nurses in the different shifts, given that each establishes their own care goals and actions without contemplating those established by their colleagues from the previous shift. In turn, NAs in the ICU-Nurses team reported that care most-often delayed, omitted, or performed with lower quality include feeding, hygiene, changes of position, measurement and disposal of collection systems: you don't have enough time to spend every hour removing residues from the bladder catheter and, for example, we must perform the change of position every two hours, not lately (B001

Termination of the NCDM in the hospital
In 2020, the gradual dismantling of the NCDM began for reasons of institutional financial sustainability. ,At the end of the NCDM the previous NAs standard and their integral patient care responsibilities were re-established . It also returned to the assignment of nurses prior to the model, although for the ICU-Nurses team and ICU-Assistants team a nurse was added as daytime support ( Table 2). The staff from the ICU-Nurses team expressed missing the care organization promoted during NCDM validity, given that it allowed nurses to get deeply involved in care, as they learned at the university, while the NAs returned to a higher level of responsibility with patients under a scheme of supervision, which is why they consider not having the accompaniment of nurses for cooperative care. The nurses from the ICU-Assistants team manifested that, in spite of having support from an additional nurse since the re-structuring of the NCDM, the possibility of performing integral care similar to that carried out in the ICU-Nurses team continues being quite limited due to the number of patients assigned.

Discussion
Comparing the ways of working from the four categories exposed permits identifying two central points of debate: implementation of an NCDM close to the professional practice desired and the influence of work environments on the quality and safety of care. The NCDM implemented in the ICU-Nurses team configured a role of care nurses by permitting a distribution of functions according with the level of legal responsibility, knowledge, and competence among the profiles integrating the work staff. Responsibility for providing care in this model was assigned to nurses, an aspect that reaffirmed their identity as caregivers, enhanced their autonomy and leadership, allowing them to offer empathetic and planned care from a holistic perspective. The NAs participated within a model with a role of articulation and support to nurses in actions of basic monitoring, hygiene, and comfort, which constitute responsibilities according with their level of training and skills.
According with Fawcett, (2) this NCDM shares some characteristics of the Team Nursing upon articulating nurses and NAs in individualized and integral patient care, optimizing the skills and resources of the work team for the quality of care. The perceptions about the care provided by the nurses in the ICU-Nurses model coincide with the study by Zamaniniya et al., (17) who state that the practice of humanistic care in ICU generates feelings, such as personal growth, self-realization, satisfaction, motivation and development of ethical competencies in nurses. In this sense, authors, like Stavropoulou et al., (18) identified as pillars of empathic care in the ICU the capacity to listen to patients, experience their feelings, understand them and help them to ease uncertainty.
The NCDM by the ICU-Assistants team assigned the nurse a role as manager and ward supervisor, which implies superficial knowledge of patients and of their care needs due to the forced delegation of the majority of care to the NAs, whose functions and responsibilities assigned overcome their knowledge and level of competence. These particularities fit within the model of Functional Nursing described by Fawcett, (2) where care is fragmented among staff members and is distanced from holistic care. The defining characteristics of this NCDM were identified in the analysis of the nursing panorama in Colombia as conducted by Ortega and Jiménez, (13) who found that most of the care in ICU requiring specialized knowledge and techniques are performed by NA; likewise, the authors indicate that nurses must delegate to NAs approximately 44% of the care of the physiological sphere that are considered by themselves as non-delegable. They also stated that the administrative work in which nurses invest the greatest amount of time could be carried out by health administrative assistants. This global problematic also emerged during the systematic revision by Blay and Roche, (19) who identified more than 200 activities delegated to NA that go beyond their training level and are conducted under limited supervision by nurses.
The comparison made permits concluding that the NCDM by the ICU-Nurses team approaches the professional practice desired in the Colombian context, understanding that the organization of work between nurses and NAs was coherent with their competencies and skills, offering better standards of quality and safety in care. However, it is worth highlighting some elements that limited the potential of the NCDM as organization tool of nursing work: a volume of patients assigned to nurses and NAs, which generates workload and omissions or delays in care, the absence of a guiding framework of the NCDM sustained in nursing models and theories, and the lack of measurements related with their economic and epidemiological outcomes.
As second point of debate, a common feature for both NCDM was work environments that compromised care quality and safety. In both ICUs, the number of patients and responsibilities assigned (some not related directly with care) generated multiple demands, limited the time and resources available from the nursing staff to provide holistic care, generated fatigue and overwhelm, and could be related with the personnel rotation identified in the description of the participants' characteristics. These factors have been identified in the analysis of barriers to empathic care by Stavropoulou et al., (18) among which there are lack of staff, increased workload, and fatigue. Some feelings emerging from the reports regarding the work overload agree with the findings by Chetty (20) and Banda et al., (21) who indicate that the workload causes a negative psychological impact on ICU nurses, manifested by anger and discouragement, emotional overburden, stress and impossibility to conciliate personal and work life. Chetty (20) also referred to the intention of leaving work and to the staff rotation as outcomes of the overburden experienced by the nurses.
Additionally, the study by Subhi (22) highlights that the nursing staff must be in charge of many things at the same time, making it difficult to complete all their activities, which affects the capacity to care for others. Thus, the omission or delay of nursing care is introduced as a specific indicator of work overload, which affects negatively on the quality of care and patient safety. As with the system of prioritizing care identified by Banda as response to workload, (21) the ICUs compared privileged care of the biological sphere over the patient's psychosocial needs, which could result in a less humanistic and more instrumental vision of care. In the nurses from the ICU-Nurses team omissions in the follow-up of care plans or education of the family distanced the work of nurses from holistic care, while for nurses from the ICU-Aides team, the impossibility to plan care, supervise that delegated, and implement prevention actions, like safety rounds or follow-up to bundles had negative implications on patient safety. For the NAs from both ICUs, omission of care related with hygiene and comfort resulted in adverse events, such as pressure wounds and pneumonia associated with ventilation. The members from both nursing teams reported feelings of frustration due to omission and delay of care, which distanced them from their ideal of patient care.
Similar findings have been reported in other qualitative research, evidencing that missed care is a global problematic and a challenge to improve the quality of health care. In this sense, Suhonen et al., (23) describe prioritizing of medical needs as an aspect that removes the nursing staff from a humanistic practice. Lake et al., (5) and Kalish (24) reported that care that is delayed or omitted most frequently encompass activities of daily life, like hygiene, changes of position and comfort, delay in some medications, communication and emotional support, education to the patient and the family. Feelings of guilt and job dissatisfaction derived from the missed care, defined by Janatolmakan and Khatony (25) also coincide with the feelings expressed by nurses and NA participating in the study.
To close this second point of debate, we summarize the findings about generating factors of work overloud and omission of care that emerged within the context of the NCDM compared and which have been identified in other qualitative research: characteristics of the patient (complexity, emergency situations), (21) of the nurse (time of experience, skills in prioritizing and delegating, articulation with NAs in decision making about care) (21) and of the work environment (staff shortage, workload, time invested in tasks not related with nursing, coordination of care with NA and medical staff). (25) To end, the following were indicated as study limitations: i) no institutional information was found that accounted for the planning and operation of the NCDM proposal of the ICU-Nurses team to triangulate such with the reports by the nursing staff and ii) adaptation of the field work to virtual methodologies in response to the COVID 19 pandemic restricted the possibility conducting participant observation and face-toface interviews, aspects that would have permitted a more-profound vision of the institutional context, work environments, and the implementation of the NCDM compared.
Regarding the contributions of the research, the results invite to improving hospital care processes by implementing NCDM and work environments that promote nursing autonomy and leadership to reach high levels of care quality and patient safety. These results also raise new questions to contribute from the investigation to the knowledge of the ethical and moral implications of missed care, the experience patient-centered care, and to deepen from quantitative methods the relationship among the NCDM, work environments, assignment of staff, patient and nursing staff outcomes. Consequently, it becomes necessary to derive knowledge from the disciplinary research to assist regulations and make administrative decisions on nursing work in the local and global scenarios.
In conclusion, the nursing teams compared perceived nursing care differently, given that this is experienced from the responsibilities assigned and possibilities of relating with patients. In the NCDM of the ICU-Nurses team, care was perceived as holistic, comprehensive, and empathetic care; while in the ICU-Assistants team, care was related with administrative leadership and management of the ICU ward. Regarding results, the NCDM in the ICU-Nurses team showed better performance in patient safety and was closer to the level of skills and legal responsibility of the NAs and nurses, in comparison to the NCDM in the ICU-Assistants team.
The experience of the NCDM developed in the ICU-Nurses team provides elements to rethink new possibilities of organizing nursing work in Colombian hospitals that are coherent with the level of training, experience, and skills of the teams of nurses and NAs, with the number of patients and functions assigned, which promote holistic care and reaffirm the autonomy, leadership, and caregiver identity of the nurses. Considering the positive results for the nursing staff and for patients of the NCDM of ICU-Nurses teams, it is recommended that the hospital institution, where said experience was carried out, to conduct complementary research from a quantitative approach and in retrospective perspective that permits evidencing the economic and epidemiological impact of enhancing the quality of nursing care, as well as establishing the impact of bedside care by nurses in the patient's health results.