Management and Delivery of Community Nursing Services in Ontario: Impact on the Quality of Care and the Quality of Worklife of Community-based Nurses

Key Implications for Decision Makers

This study investigated the effect of the competitive model for awarding homecare nursing services by community care access centres in Ontario on the quality of care, and on nurse and client outcomes.

  • Clients cared for by for-profit agencies reported slightly higher quality of care and higher satisfaction than clients cared for by not-for-profit agencies.
  • Nurses felt quality of care was the same at for-profit and not-for-profit agencies.
  • Most access centres and agency managers believed that quality of care and quality improvement initiatives had either remained the same or improved, although some not-for-profit agencies believed the quality of care has declined.
  • Policy makers should focus on providing opportunities for full-time or regular part-time employment (rather than casual employment), providing employment benefits, and providing nurses with more time to provide care.
  • Clients functioned better on social and emotional levels when more visits were made by registered nurses (as opposed to other classes of nurses).
  • Having clients be consistently seen by the same nurse was associated with lower nursing costs but was not related to client health.
  • The likelihood that clients would be seen consistently by the same nurse did not depend on whether the agency was for-profit or not-for-profit. It was more likely when agencies were awarded longer contracts.
  • Nurses reported moderate work enjoyment and low satisfaction with their time for care and job security. There were no differences based on whether they worked for a for-profit or a not-for-profit agency.
  • Nurses who were compensated for their work on an hourly basis reported higher satisfaction with the time for care than those reimbursed per visit.

Executive Summary

Background

In 1995, the Ontario Ministry of Health and Long-Term Care created 43 community care access centres, which were charged with the responsibility of awarding service contracts to provider agencies using a competitive "request for proposals" process. Both for-profit and not-for-profit agencies submit proposals to the centres in response to requests for proposals, and in turn are awarded contracts for pre-determined periods of time. The Community Nursing Services Study described this model and examined its impact on nurse and client outcomes.

The study was conducted in two phases. The report of the first phase was released in August 2002. It described how the competitive bidding process was being put into operation, including the volumes and costs of nursing visits for for-profit and not-for-profit agencies during the first five years of competitive bidding. The report can be read at www.nursing.utoronto.ca/faculty/bios/CNSS_Phase_1_Reportb.pdf.

Objectives

The objectives of the second phase of the study were to examine the relationships between variables in the structure of the contracts and:

  • quality of care;
  • client outcomes;
  • cost of care; and
  • nurse outcomes.

This report describes the second phase of the study.

Findings

There were few differences in quality of care based on the contract length, contract volume, or whether the agency was for-profit or not-for-profit. Clients cared for by for-profit agencies reported higher quality of care and higher satisfaction than clients cared for by not-for-profit agencies. There were significant differences in nurse quality outcomes among provider agencies. The more consistently the client was seen by the same nurse, the lower the nursing costs were. Consistency did not affect client health outcomes. Clients who were healthier when they were admitted to homecare were still healthier six weeks later or at discharge. More visits made by a registered nurse were related to better emotional and social functional outcomes. Older nurses and nurses who worked part-time enjoyed their work more than younger nurses and those who worked on a casual basis. Nurses who were compensated on an hourly basis reported higher satisfaction with time for care than nurses who were compensated on a per visit basis. Nurse turnover was not related to contract variables or ownership type.

Design

A longitudinal design was used to collect data on client outcomes twice: at admission to homecare or recruitment into the study; and at discharge or after six weeks, whichever came first. Nurses, agencies, and access centres were surveyed using written questionnaires and data abstraction from corporate databases.

Setting/Sample

The setting consisted of 11 community care access centres and 11 nursing agencies. The sample included 740 clients and 700 nurses.

Variables

Structural variables included information on client demographics, diagnosis, health status, anticipated duration of service, nurses' experience, employment characteristics, agency ownership structure (that is, for-profit or not-for-profit), contract length, and contract volume. Process variables included clients' and nurses' perceptions of the quality of nursing care, consistency of care provider, and percentage of visits by a registered nurse or a registered practical nurse. Outcome variables included costs of nursing care, client satisfaction with care, client health outcomes, nurse work enjoyment, satisfaction with time for care, perception of job security, and annual nursing turnover.

Methods

Clients completed a structured questionnaire on admission to the study and again after six weeks (or sooner if discharged). Nurses, access centres, and agencies completed written questionnaires once. Analysis was conducted using hierarchical linear modeling.

Implications

Whether a nursing agency is for-profit or not-for-profit was not strongly related to the quality of services it delivers. Variations in quality existed among both types of ownership structures. This suggests it is important to develop a better understanding of the management and care practices that are most influential in promoting quality performance and better outcomes for clients in the home healthcare setting.