Conceptual Framework Use to Study Health Care Outcomes

Conceptual Framework

The proposed study will concentrate on the use of the conceptual framework to study health care outcomes. Holzemer (1980) used Donabedian’s model to develop The Outcomes Model for Health Care Research. Mitchell, Ferketich, and Jennings (1998) assert that the healthcare industry has had major changes in the past. Some of the changes have emphasized the creation of environments that support outcomes other than structure and processes (Mitchell et al., 1998).

Donabedian model is the best example of a conceptual framework that adopts an extensive use of the three elements (Donabedian, 2005). Donabedian’s model has shaped the study of quality attributes of every health care setting (Donabedian, 2005). The Donabedian model requires information about the quality of care to come from three areas- structure, processes, and outcomes (Mitchell et al., 1998). Accordingly, each category has its meaning within the framework. First, ‘structures’ refers to the context in which the health care is provided, including the staff, equipment, buildings and financial sources. Secondly, processes are the relationships between providers and clients. The outcomes refer to the impact of health care delivery on patients and the general population. Although the first model was developed by Avedis Donabedian in 1966, there are several other frameworks in existence. However, the Donabedian Model is the dominant method for assessing healthcare quality (Murray & Frenk, 2000).

Holzemer’s Outcomes Model for Health Care Research involves more input than Donabedian’s model. Holzemer (1994) used the model to increase the efficiency of evaluating health care activities that impact health care outcomes, for example, nursing activities. This was made possible by designing a complex matrix that enhanced the understanding of factors correlated with health outcomes. However, structure as described by Donabedian, which is well suited to institutional environments, does not have inputs or characteristics of care as contained in Holzemer’s model. The Outcomes Model for Health Care Research analyzes the client, provider, setting, inputs, processes, and outcomes. The structure involves the vertical and horizontal axes, which as shown in figure 1 below.

Inputs Process Outcomes

Figure 1.

The Outcomes Model for Health Care Research


Client Inputs

Client inputs could be personal attributes that a client may control, for example, personal strength. Client inputs could also be factors that a client could have little control over, for example, cultural beliefs. The client attributes determine the wellbeing and quality of life of patients. In fact, it has been shown that most of the client variables positively correlate with health outcomes.

It is proposed that a health care provider must analyze related information to decipher factors, values and beliefs that could impact health care outcomes. “The framework assumes that clients live in a social environment with cultural values and beliefs about their health and health care. These values and beliefs affect the individual’s desire and ability to interact with the health care system. (Holzemer, 1994, p. 6). This is a marked extension of organizational structure as defined by Donabedian (1980).

Client activities or processes

Holzemer (1994) defines client processes or activities as practices that individuals utilize to impact their health status. These may include resources at the individual, family or community levels. Holzemer and Reilly (1995) showed that diet, exercise, and smoking impacted individual health care outcomes. Individuals who took poor diets had more chances of developing diseases than those who took a balanced diet. Persons who hardly exercised had more chances of encountering poor health outcomes. Smoking by individuals was found to negatively impact their health care outcomes. Apart from self-care practices, informal supports could also be used by individuals to foster health outcomes. Informal supports could involve the use of material and nonmaterial resources at the family or community levels.

Client or patient outcomes

Client outcomes are changes in patient health status that are influenced by health care interventions (Holzemer, 1992; Stewart, 1995). It is the goal of health care providers to promote the health care status of an individual. However, it has been shown that it is quite difficult to measure patient outcomes because they are impacted by a combination of variables. In addition, it is difficult to understand the resulting effects of the many factors that could have an influence on an individual’s health status. Mitchell and Shortell (1997) showed that the physiological status, psychological status, functional status, and quality of life of an individual have a great impact on personal health outcomes. It has also been demonstrated that health outcomes brought about by chronic disease or health conditions are different from those resulting from acute diseases or health conditions (Cohen, Saylor, Holzemer & Gorenberg, 2000). Cohen and colleagues (2000) argue that elderly persons suffering from chronic diseases or health conditions may aim to maintain their current status or minimize the negative impact of the diseases or health conditions. This observation is consistent with the fact that the main objective of health care is to help individuals receiving health care attain the highest level of health status (Holzemer, Henry, Reilly & Portillo, 1995).


Provider inputs

Provider inputs are contributions made by health care professionals to patients toward achieving optimal health status. Health care providers could also be informal members in the community who provide health care to patients. Currently, the education, expertise, technical or scientific skills, and experience of health care providers are regarded as crucial components of health care providers that go a long way in promoting health care among individuals (Holzemer et al., 1995). It has been shown that professional education, standards, and experience of health care providers positively correlate with improved health care outcomes (Benner, Tanner & Chesla, 1992; Holzemer, 1992).

Provider processes

Provider processes are activities undertaken by health care providers to promote the health care outcomes of patients (Cohen, Saylor, Holzemer & Gorenberg, 2000). Nursing activities and interventions are of interest, according to Holzemer’s model (Holzemer, 1992; Holzemer, 1994). Clinical procedures and standardized nursing care plans have been shown to impact health care outcomes across the world. Health care providers conduct assessments on the effectiveness of provider processes by determining related health care outcomes. The assessments are also used to develop approaches to improving health care among patients. However, as noted earlier, assessment of provider processes is difficult as a result of the complexity of provider/patient interplays (Mark, Salyer & Geddes, 1997).

Health care provider outcomes

These are components of health care professional practice that impact health care provider competence, satisfaction, or lower cost of care. Holzemer and colleagues (1995) have positively correlated acute care setting professional models with better provider satisfaction and quality of health care.


Setting inputs

A health care setting is defined as the environment in which health care providers provide health care services to patients. Health care settings are defined by characteristics that differ from one healthcare organization to another (Holzemer, 1994). Health care setting has been accorded some geographical components to imply that the physical location could influence patterns of health and illness (Popay, Williams, Thomas & Gatrell, 1998). The geographical approach to health care setting allows health care professionals to decipher a combination of environmental factors that influence health outcomes in individuals. Health care outcomes have also been shown to be affected by the economic status of groups of people. Low-income communities experience numerous barriers to care such as lack of health insurance associated with low-level employment, lack of transportation, and fewer available services. Health care organizational setting inputs have been crucial components in health care quality assessments and interventions (Holzemer et al., 1995).

Setting processes

Setting processes are characteristics and activities of health care organizations that influence health care professional practice and quality of health care (Holzemer, 1994; Holzemer et al., 1995). Holzemer and colleagues (1995) identify planning, policy development and implementation, and decision making within health care organizations as some of the setting processes that influence health care outcomes. Health care organizations implement quality management systems to assess health care performance and patient outcomes.

Health care setting outcomes

Health care organizations use health care setting outcomes in the identification and evaluation of health care inputs and processes that influence health care outcomes. Health care setting outcomes are the primary focus of quality management assessments that aim to use organizations’ data to evaluate the effectiveness of health care inputs. Health care professionals use benchmarking strategies to define and align health care outcomes within many health care organizations (Holzemer et al., 1995).

Use of the Outcomes Model for Health Care Research

Holzemer (1992) asserts that the Outcomes Model for Health Care Research is a very important framework that is used to demonstrate the effectiveness of nursing care by correlating nursing processes with patient outcomes. The model is crucial in the identification of variables that influence health care outcomes. Holzemer defines quality nursing care as “activities that have been empirically linked to patient problems and patient outcomes” (Holzemer, 1992, p. 429).

Holzemer (1994) describes the utilization of the Outcomes Model for Health Care Research in the study of primary health care settings. The researcher analyzed the following health issues: childhood illness, women’s occupational health, and the increasing incidence of HIV. Holzemer and Reilly (1995) used the model with the aim to determine aspects that could be improved. The study researchers analyzed interactions between patient outcomes and the various aspects of the matrix. The outcomes that were identified were patient physiologic status, psychosocial status, functional status, and quality of life. In addition, the researchers positively correlated provider-client activities with client outcomes. The best-studied client processes are the self-care practices that are used to explain much of the differences in client health outcomes. Holzemer et al., (1995) used the Outcomes Model to link provide inputs and activities to patient outcomes. Other studies on provider activities have concentrated on the utilization of standardized activities (processes) like the application of critical pathways and standardized care plans (Holzemer et al., 1995). Fongwa (2001) conducted a quantitative study based on the Outcomes Model for Health Care Research to determine the perceptions of African Americans regarding the quality of health care. The study found that provider, patient, and setting roles were regarded by group respondents as aspects of high-quality care.

Studies have been conducted at the setting level to determine the impact of factors that influence health care outcomes (Holzemer, 1994). Holmezer and colleagues (1995) investigated organizational attributes that play crucial roles in shaping aspects of the organization and patient outcomes. A recent study by Krairiksh and Anthony (2001) used Holzemer’s outcomes model to determine the interaction among organizational leadership, setting processes and nurses’ decision making. The study findings supported findings from an earlier study that focused on organizational structure, organizational processes, and decision making (Krairiksh & Anthony, 2001).

Summary of the Theoretical Model

In conclusion, the Outcomes Model for Health Care Research was proposed to be used as a conceptual framework to assess quality of health care. It provides a depth of analysis that is crucial for understanding the many variables that impact health care outcomes. The model uses a matrix to study the interaction of many aspects of health care that influence health outcomes (Holzemer, 1994). The model proposes client and community factors that correlate with nursing care outcomes. However, the relationship between provider attributes and processes has been found to be less conclusive (Holzemer, 1994). Although a limited number of studies have focused on the relationship between organizational inputs and patient outcomes, the conceptual model should be used at the setting level. At the setting level, the model would specify the conceptual units of interest and provide direction on the best approaches to use in the differentiation of setting level variables from provider-level variables.

Analysis and Limitations of the Outcomes Model for Health Care Research

Although the Outcomes Model for Health Care Research has been the conceptual framework for several nursing studies, the approach has been underutilized in nursing research. It could be due to the fact that Donabedian’s model is more common with nurses and nurse scientists across the world. In addition, a similar model has been developed for the study of the quality of health care outcomes within health care organizations (Mitchell et al., 1998). The outcomes contain all the resultants of the health care system. It must include all the effects and impacts of delivery on the patients. One of the challenges in the use of the model is that researchers must use a large sample population and a long follow-up period in studying these aspects. This is difficult because outcomes may take a long time to show evidence of the success or failure of the structures or processes. It is worth noting that the model lacks a specific definition of quality care. Limited use of the Outcomes model may also be due to the difficulty in defining the aspects of care and deciding where to locate them on the Outcomes matrix. Clear operational definitions are required to effectively use the matrix.

Popay and colleagues (1998) suggest that linearly structured models like the Outcomes Model may not be appropriate to understand the interaction among activities that influence patient outcomes. To understand dynamic systems within health care organizations, studies involving factors and processes must be conducted. To address this shortcoming, the Outcomes Model has been adjusted to better address the interaction among inputs, processes, and outcomes within health care organizations.

Conceptual Framework Guiding this Study

The conceptual model that guides this study is the Outcomes Model for Health Care Research (Holzemer, 1994). The proposed study will focus on the hospital setting. In particular, the data will be obtained from nursing records taken during the patient’s process and history of admission in the Electronic Health Record (EHR) nursing used to support discharge planning. The study focuses on the first 24 to 72 hours from the initial admission of the patient to the facility. Relationships between Agency characteristics, hospital size/type community characteristics, and socio-demographic factors, particularly age, self-reported walking limitation, prior living status, level of disability, and the health outcomes of healthcare patients. While the depiction of the model in a matrix is helpful in understanding the various levels (patient, provider, and setting) it obscures the relationships within the same level. Thus, since this study is investigating the interplay of organizational factors at the setting level, the matrix has been replaced by inter-connecting circles that depict the interaction of setting input, process, and outcomes (Figure 2). The organizational concepts of agency characteristics, health care service use, and patient outcomes are linked as depicted by the interconnecting circles. The depiction of the model as inter-connecting circles indicates the interrelationships among the study concepts. The circular areas represent the concepts with overlapping areas indicating critical relationships. The bold font represents the constructs, the concepts are in italics and the indicators are in normal font.

Conceptual Framework.
Figure 2 Conceptual Framework.

The circle labeled “Inputs” represents the setting – the Patient Characteristics are the inputs to the system of care. The circle labeled “Process” represents the organizational activities. In this study, the process will be used to identify patients suitable for early Discharge Planning intervention. The circle labeled as “Outcomes” represents the length of stay, Bed capacity, Refusal rate and Readmission rates. The intersecting areas imply that the study concepts are related. The center area where all three circles overlap can be considered the reality of clinical practice (Bolman, 1995). The diagram of the conceptual framework represents the healthcare practice reality containing inputs, processes and outcome components. Less apparent is that the diagram also depicts our knowledge of the relationships between the concepts as described in the following sections.

The Intersection of Inputs (Patient Characteristics) and Process (ESDP)

Setting inputs there are four patient characteristics readily available on admission that may influence the process of Early Screen for Discharge Planning (ESDP): age, self-reported walking limitation, prior living status and level of disability. The score range from 0 to 23, patients with a cut-point score of 10 or greater should be highlighted to receive attention from a Discharge Planner early in their hospital stay (Holland, Harris, Leibson, Pankratz & Krichbaum, 2006).

The Intersection of Process (ESDP) and Outcomes

Setting processes include organizational activities involved. For instance, it includes such activities as diagnosis, medication, treatment, patient education, and preventive care. In this study, setting processes are the Early Screening Discharge-Planning (ESDP) for patients to determine bed capacity in a health care center, average length of stay in a healthcare center, readmission and refusal rate. The relationship between ESDP score and patient outcomes being practiced in Saudi Arabia is the first phenomenon to be explained.

The Intersection of Inputs (Patient Characteristics) and Outcomes

The desired goal or outcome of health care organizations is the achievement of optimal patient health (Holzemer, 1994; Holzemer et al., 1995). Outcomes at the setting level are patient outcomes reported as comprehensive data. In a healthcare setting, patient outcomes are often measured as a change in patient health status during an episode of care (Shaughnessy, Crisler, Schlenker & Arnold, 1997). Commonly studied home health care patient outcomes are patient hospitalization, use of emergent care, and changes in patient’s functional status. There are few studies of the relationship between patient characteristics and patient outcomes. A recent study found that patient characteristics were more likely to be contributing factors

Research Questions

The research questions proposed in this study examined the interplay of Patient Characteristics, processes and patient outcomes. The degree of Patient Characteristics affects patient outcomes both directly and indirectly through service use (ESDP) score. Patient Characteristics are also proposed to have a direct effect on healthcare service use (ESDP) score.

  1. Is there a direct effect of the degree of Patient Characteristics of healthcare centers on patient outcomes (Length of stay, Bed capacity, Refusal rate and Readmission rates)?
  2. Is there a direct effect of degree of Patient Characteristics of health care centers on the Early Screen for Discharge Planning score (ESDP)?
  3. Is there a direct effect of the degree of Early Screen for Discharge Planning score of healthcare center on patient outcomes?
  4. Is there an indirect effect of the degree of Patient Characteristics on patient outcomes through healthcare center service use?
  5. How do Patient Characteristics affect (ESDP) score and patient outcomes?

Significance to Nursing Science

The nursing profession aims to develop knowledge that would have great impact on patients care for by nurses. Globally, nurses are expected to address many patient needs without any form of discrimination on the basis of social-economic status, color or education levels (Hinshaw, 1989). Hinshaw (1999) proposes the best guidelines for the development of nursing knowledge across the world. She isolates specific areas in the field of nursing that are crucial in the development of knowledge. For example, she suggests that the nursing field should be accountable to the society through accumulation of evidence-based nursing practices. to society, to build a cumulative science, and to develop knowledge to guide nursing practice (Hinshaw, 1989).

The field of nursing is required to find solutions to cater to the health needs of patients in society. The impact of the nursing field is greatly determined by how nurses respond to the needs of individuals in the society. Nursing research plays a crucial role in searching for knowledge that would culminate in improved patient outcomes. Thus, nursing science is a broad area of study that studies attributes of human responses to health and illness within the context of the environment and other paradigms (Hinshaw, 1989). Pierce, Hazel and Mion (1996) assert that nurses have all along been concerned about caring for vulnerable individuals in society. Individuals could be vulnerable due to inequalities in access to health care and poverty. This study will clearly focus on the nursing paradigm to address issues related to patient characteristics to describe the post-acute care needs in Saudi Arabia.

A bigger percentage of vulnerable health care patients are elderly women in rural settings across the world. It has been demonstrated that older women in society have more chances of having limited access to resources that are crucial in attainment of quality health status (McNally, Wareham, Flemming, Cruickshank & Parkin, 2003). Meleis (2005) recommends that nursing research could be used to understand health concerns and experiences of patient populations care for by nurses across the world. Nursing practice should aim to adopt a holistic approach that identifies, describes, and explains different patient needs. Informed nursing research uses prior nursing evidence and knowledge to build upon the knowledge that would be used to improve patient outcomes within the health care industry. For example, Hinshaw (1989) identifies the advantages of having a depth of knowledge in a given area through the analysis of findings from multiple similar nursing studies. This study will build upon and extend the body literature to develop knowledge about the relationship of use (ESDP) score and patient outcomes. This study will examine the relationships between the degree of patient characteristics, (ESDP) score, and patient outcomes. Factors affecting systems of care affect the patients within the system (Pierce et al., 1996). Thus, understanding the relationships between patient characteristics, healthcare services, and patient outcomes will facilitate nursing interventions to promote and support health care patients. Because nursing is a practice discipline, nursing science is obligated to develop knowledge that makes a contribution to nursing practice. Meleis (2005) indicates the importance of knowledge development not only within nursing’s broad paradigm, but also to address the specific priorities of the numerous populations served by nurses (Meleis, 2005). Health systems research is valuable in informing nursing practice – it provides the interface between practice and policy that impacts populations served by nurses. This study will inform practice in the home healthcare arena. The findings from this study will be particularly important for healthcare center nurses who provide care that supports and enhances patient health outcomes.


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