Journal of Nursing Management, 2007, 15, 188–196

A conceptual framework contributing to nursing administration

and research

1 2 3
ALAIN D. BIRON RN , MARIE-CLAIRE RICHER RN and HÉLÈNE EZER PhD, RN
1
PhD Student, Ferasi Fellow, 2PhD (cand.), Ferasi Fellow and 3Associate Professor, School of Nursing, McGill
University, Québec, Canada

Correspondence (2007) Journal of Nursing Management 15, 188–196

BIRON A.D., RICHER M.-C. & EZER H.
Alain D. Biron A conceptual framework contributing to nursing administration and research
School of Nursing
McGill University The health care system has undergone major changes in the last decade. With
3506 University Street greater acuity and complexity of illness, the adoption of innovative technologies and
Wilson Hall the shortage of health care personnel, the coordination and integration of health
Montreal care services has become increasingly demanding for administrators. Growing dis-
Québec H3A 2A7 satisfaction and concerns about safety issues are being expressed by the users of care
Canada who need to navigate through an increasingly complex system and by health care
E-mail: alain.biron@mail.mcgill.ca personnel who feel less efficient within the organization. Nursing administrators
have a responsibility to address these issues but there is little scientific evidence to
guide their actions. There are also few comprehensive models highlighting the main
components of nursing administration – models that could guide nursing adminis-
tration research. This paper presents a conceptual framework for nursing admin-
istration and research that links patient health care needs, nursing resources and the
nursing care processes to the context of the health care system, and the social,
political and cultural environments of care. A selected review of the oncology and
cancer care literature is presented to demonstrate how this framework can organize
existing knowledge about these concepts in the context of cancer care.
Keywords: cancer care, health care needs, nurse outcome, nursing administration,
nursing administration research, nursing care process, nursing resources, patient out-
come, system outcome

Accepted for publication: 8 March 2006

for patients, nurses and administrative units is required

Introduction
The delivery of health care is affected by increasingly
complex social, political and economic factors. In
addition, the challenges of hospital closures and merg-
ers and human resource shortages have brought to light
inefficiencies within health care systems. As the worldsÕ
largest group of health care providers, Schultz (2004)
situates nursing in a unique position to establish a sci-
entific basis for improving the global care of individuals
and families in the 21st century. To achieve this, a clear
understanding of the components influencing outcomes
to build evidence for administrative decision-making.
While the purpose of nursing services administration is
to design, manage and facilitate coordinated patient
care (Beyers 2004), in an evidence-based decision-
making era, the goal of research in nursing adminis-
tration was to develop the knowledge that provides a
scientific basis for nursing administration practice
(Lynn & Layman 1996).
In an argument for nursing administration research,
Jennings (2004) makes the distinction between research
in nursing administration and research in health

188 ª 2007 The Authors. Journal compilation ª 2007 Blackwell Publishing Ltd

services, suggesting that the fields are complementary
and would benefit from each other’s strengths. She
notes that economic and political issues are not suffi-
ciently addressed in nursing administration research,
while health services research has used primarily eco-
nomic measures to assess patient and provider out-
comes and would benefit from the nursing perspective.
The integration of these approaches would more closely
reflect the complexity of health care organizations
(Glouberman & Mintzberg 2001, Glouberman &
Zimmerman 2002) and the recognition of the specific
contributions of nursing administration in the man-
agement of health care (Mintzberg 1994, 2002). It is
also consistent with the shift to an open systems
approach that situates components of the organization
in a dynamic and interdependent relationship with the
environment (Heffron 1989, Beyers 2004).
Given the impact of economic and socio-political
factors on health care delivery during the last decade,
nursing administrators as well as researchers in nursing
services administration are increasingly concerned about
the interplay of factors in the delivery of care. Factors
that have been examined include nurse staffing and
mortality (Aiken et al. 2001, Tourangeau et al. 2002),
staffing and safety (Rogers et al. 2004), nursing educa-
tional levels and mortality (Aiken et al. 2002), and
organizational factors and perceptions of well being
(Richer & Ezer 2002). Significant new knowledge has
been generated by nursing researchers using models that
address specific elements influencing the delivery and
outcomes of care. For example, one group of researchers
(Schaffner et al. 1999, O’Brien-Pallas et al. 2001c,
2002, Houser 2003) has focused on methods of nursing
care delivery and patient care outcomes. Others have
addressed quality of health care (Mitchell et al. 1998),
or the planning and forecasting of human resources
(O’Brien-Pallas et al. 2001a). In specific areas such as
cancer care, research models have also focused on one
dimension of administration, such as cost and patient
outcomes (Lee et al. 2000), strategies to control cancer
incidence (Abed et al. 2000) or have subsumed nursing
administration concerns within a larger framework of
the delivery of cancer care (McIlfatrick et al. 2004).
In addition to considering selected factors that influ-
ence care delivery, administrators with the responsibil-
ity for planning services for specific populations
including cancer must ensure that nursing services are
congruent with the geographic and socio-political
environments in which they are delivered (Abed et al.
2000, World Health Organization 2002, Sullivan et al.
2004). Economic and political circumstances have
markedly reduced the availability of health care
ª 2007 The Authors. Journal compilation ª 2007 Blackwell Publishing Ltd, Journal of Nursing Management, 15, 188–196
Nursing administration
resources in the last decade (OECD Health Project
2004). These situations prompted administrators to
focus on balancing budgets and controlling costs by
changing governance structures or reducing managerial
positions (Lomas & Contandriopoulos 1994). These
decisions have had consequences. Reduced participa-
tion of nursing managers in organizational decision-
making has had a negative impact on nursesÕ job
satisfaction, turnover and retention (Aiken et al. 2002,
CNAC 2002). Those same factors of job satisfaction,
turnover and retention have also been associated with
nursesÕ perception of decreased quality in the care
provided to patients (Aiken et al. 2002). Mitchell and
Lang (2004) have argued that to improve patient care,
researchers, policy-makers and administrators need to
take a comprehensive approach that integrates all as-
pects of the health care system, from the organization’s
specific context to the economic, political, social and
cultural environment.
While each of these dimensions is important to nur-
sing administration research, they need to be considered
as a part of an interactive framework that describes the
relationships between factors that influence care deliv-
ery. Such a framework would facilitate the organization
of current knowledge, help identify the gaps and guide
nurse administrators in translating research findings
into practice by contextualizing the results. It would
also provide a distinctive way of conceptualizing nur-
sing administration research and practice by illustrating
its unique contribution to the larger field of health
services research. The conceptual framework illustrated
in Figure 1 views nursing administration as an open
system with four core components – patientsÕ health
care needs, nursing resources and nursing care processes
– each having a direct influence on patient, provider and
system outcomes. These components are also mutually
dependent and influenced by the specific health care
organization and by the political, social, cultural and
economic environment.
Patient, nurse and system outcomes
Since the 1990s the issue of outcomes has been at the
heart of debates about cost, quality, effectiveness of
care and organizational performance. This interest is
related to greater expectations for accountability from
administrators and policy-makers (Doran 2003).
Researchers also see outcomes as a critical concern and
have proposed different classification schemes. Most
have considered patient outcomes (Johnson & Maas
1998, Doran 2003); others have also addressed provider
and systems outcomes (Lohr 1988, Holzemer & Reilly
189
A. D. Biron et al.
ical - social - cultural - econ
Polit environment
omic
lth care organization
Hea
ministration and re
g ad sea
rsin
Nu
Patient health Nursing care
care needs processes
Outcome
Patient
Nurse
System
Nursing
resources
1995, Jennings et al. 1999). Outcomes are situated at
the centre of the proposed framework (Figure 1) and
are considered the ultimate indicators of the impact of
administrative decision-making. The goal of both nur-
sing administration and nursing administration research
is to positively influence outcomes for patients, care
providers and for the system itself.
While there is agreement among practitioners and
researchers that patient outcomes are critical variables
to consider in health care, patient outcomes indicators
tend to focus on what Lohr (1988) has called the five Ds:
death, disease, disability, discomfort and dissatisfaction.
One example is the use of mortality and failure to rescue
in acute care hospitals as a patient outcome related to
organizational characteristics (Aiken et al. 2002,
Tourangeau et al. 2002). The selection of such patient
outcome measures can be explained by the fact that
these indicators are readily available in patient records
(Doran 2003). However, these epidemiological indica-
tors are not always sensitive to a broad range of nursing
interventions that have a significant impact on patientsÕ
experiences with illness. Major efforts are being made to
expand the repertoire of patient outcome measures to
include clinical indicators related to patientsÕ symptom
experience, functional status, nutritional status, safety
and psychological distress (Oncology Nursing Society
2003). These clinically based measures are still infre-
quently used in nursing administration research, but are
consistent with the concept of nurse-sensitive patient
outcomes suggested by Johnson and Maas (1998) that
reflect a patient or family caregiver state, behaviour, or
190 ª 2007 The Authors. Journal compilation ª 2007 Blackwell Publishing Ltd, Journal of Nursing Management, 15, 188–196
rch
Figure 1
A nursing administration framework
for researchers and administrators.
perception that is measurable along a continuum and is
responsive to nursing interventions.
Administrative decision-making also has an impact
on nurses (O’Brien-Pallas et al. 2004). Nurse outcomes
can be viewed as measurable cognitive, emotional or
behavioural states that are responsive to systems
change. There is large body of literature that has
focused on nurse outcomes. Researchers have used
burnout, autonomy, job satisfaction and heath status
(Aiken et al. 2001, O’Brien-Pallas et al. 2004) as
measures of the impact of health care systems on nurses.
Literature reviews on turnover in nursing staff also
describe organizational characteristics of workload and
work schedules as determinants of job dissatisfaction,
stress and burnout among nurses (Tai et al. 1998,
Newman & Maylor 2002).
System outcomes are frequently reflected by a mix of
patient, nurse and system-specific indicators. The
overall objective of measuring system outcomes was to
evaluate both the system effectiveness and efficiency.
System effectiveness refers to the extent to which care
achieves its intended outcome, while efficiency refers to
the ratio between cost and benefits of care (Campbell
et al. 2000). Report cards are tools used by nurse
administrators to facilitate system effectiveness evalua-
tion. It allows comparison of core system indicators
related to nursing administration across similar hospi-
tals using predefined categories, such as the utilization
of nursing resources, financial performance, system
integration and change and patient outcomes (Moore
et al. 1999, McGillis Hall 2002).

There are relatively few well-developed system-spe-
cific measures that are responsive to changes in nursing
human resources and care processes. Some measures do
exist – quality of the work environment has been used
to describe systems characteristics in the magnet hos-
pitals (Aiken & Patrician 2000, Estabrooks et al. 2002,
Kramer & Schmalenberg 2005). However, a greater
number and variety of reliable and valid system
indicators would enable researchers to go beyond
aggregated patient, provider and cost data to monitor
the systems effectiveness. Such measures would help
researchers to go beyond descriptive studies and begin
to explore the nature and direction of relationships
between patient health care needs, nursing resources,
care processes and system outcomes.
Aligning needs, resources and processes to
outcomes
Patient health care needs
Traditionally, economists and social scientists have
explored the concept of population health care needs
within the context of the notions of equity and equality
(Culyer & Wagstaff 1993, Raine et al. 2003). It is only
recently that nursing researchers have expanded their
approach and examined patient health care needs,
within a particular economic and political context
(Nosek 2004, Schultz 2004).
In Fitch’s (1994) view of supportive cancer care,
health care services are provided to meet physical,
social, emotional, informational, psychological spirit-
ual and practical needs as defined by the patient.
Sanson-Fisher et al. (2000) defined patient health
care needs as the requirements for resources or
actions that are necessary, desirable or useful to
attain optimal well-being. In the context of cancer
care, health care needs are key drivers to the organ-
ization of health care and nursing services. However,
only a few studies evaluate specific health care
needs of the cancer population (Raich et al. 1997,
Wilson et al. 2000). Some studies have examined
met and unmet health care needs among cancer
patients at different periods in the illness trajectory
(Grande et al. 1997, Raich et al. 1997, Whelan et al.
1997, Girgis et al. 2000, Wilson et al. 2000). Others
have addressed cancer patientsÕ health care needs
indirectly by measuring patient satisfaction with the
health services that are offered. These patient satis-
faction studies have identified specific gaps in the
services offered to the cancer population. For exam-
ple, issues of waiting time and the lack of information
ª 2007 The Authors. Journal compilation ª 2007 Blackwell Publishing Ltd, Journal of Nursing Management, 15, 188–196
Nursing administration
regarding medication or care have been identified as
priority actions that need to be addressed in outpa-
tient oncology centres (Gourdji et al. 2003, Gesell &
Gregory 2004).
Ongoing evaluation of population health care needs is
essential for decision-makers. As the prevalence of
cancer continues to grow (Jemal et al. 2004), issues
related to the organization of services are particularly
important in providing optimum care to this population
(Ragaz 2004). For example, while the reorganization of
resources has markedly reduced patientsÕ length of stay,
the increase in radiotherapy treatments, the refinements
in chemotherapy regimens and in the management of
concomitant side effects, has resulted in an increase in
outpatient treatments. This has resulted in fragmenta-
tion of care as health care providers from different
services or organizations see patients on a sporadic
treatment-related basis. In fact, despite national prior-
ities for the integration of services in cancer care in
many countries of the world, the fragmentation of care
continues to be evident (Abed et al. 2000, Gray et al.
2002, World Health Organization 2002, Sullivan et al.
2004).
Nursing resources
Nursing resources are the human, financial and material
resources that can be deployed by nursing administra-
tion to meet the health care needs of the population.
Economic and political circumstances have markedly
reduced the availability of these resources in the last
decade (OECD Health Project 2004). Health care sys-
tem administrators implemented major restructuring
initiatives during that period in an attempt to control
health care expenditures. This reduced expenditure
frequently resulted in a decrease in the number of nur-
ses, lower budgets for nursing functions within the
health care system, and a decrease in the availability of
equipment and supplies for carrying out nursing care
(Baumann & Blythe 2003).
Nursing resources have been linked to patient, pro-
vider and system outcomes. For example, after adjust-
ing for patient and hospital characteristics (size,
teaching status and technology), each additional patient
per nurse was associated with a 7% increase in the
likelihood of dying within 30 days of admission and a
7% increase in the odds of failure-to-rescue (Aiken
et al. 2002). The impact that nursing human resources
may have on patient, provider and system outcomes
raises concerns among providers in cancer care. In a
survey of health professionals working in oncology,
more than 56% registered nurses perceived staffing as
191
A. D. Biron et al.
inadequate (Buerhaus et al. 2001). Cancer care profes-
sionals perceive staffing inadequacy as a major source of
job stress and results in a decreased quality of care
provided (Grunfeld et al. 2005).
While there are known consequences to a decrease in
nursing human resources, the full systemic impact of the
human resources shortage on patients, providers and
organizations in cancer care is still unknown. In part,
this is related to the fact that most research linking
human resources and outcomes is not diagnosis-specific.
Little evidence exists to guide the decision-making of
nurse administrators regarding human resources in
terms of the education, skill mix and numbers that
ensure the most effective care for cancer patients
(Richardson et al. 2002). In an attempt to address this
issue, the Oncology Nursing Society called for greater
research attention to the contribution and efficient use
of all health care professionalsÕ skills in cancer care
(Oncology Nursing Society 2002).
Nursing care processes
Processes of care are all the activities involved in pro-
viding care to patients and their families. These include
not only clinical interventions, but also the different
contributions of professional and non-professional
activities in the care episode. If nursing resources are the
personnel, finances and materials that can be mobilized
to meet the patient needs, than nursing care processes
represent how these resources are used to meet those
specific needs. Clinical research establishes how a given
nursing intervention may produce favourable patient
outcomes. Processes of care studies examine how
interventions based on research evidence are utilized
within health care organizations and their associated
outcomes. The challenge associated with studying pro-
cesses is that ineffective care processes do not neces-
sarily result in adverse patient outcomes particularly
when measured by death and disability (Crombie &
Davies 1998). As a result, administrators or policy-
makers may mistakenly assume that nursing care pro-
cesses are not relevant.
For the most part, existing studies have linked nursing
human resources and outcomes without specifying the
underlying nursing care processes (Cho 2001, Sidani &
Epstein 2003). There are very few studies on how nur-
sing processes result in favourable outcomes. Part of the
reason is related to measurement issues (Kahn et al.
2002). An additional factor has also been the insufficient
attention given to processes of care that are effective.
Such studies would require participative and evaluative
designs, such as appreciative inquiry (Cooperrider &
192 ª 2007 The Authors. Journal compilation ª 2007 Blackwell Publishing Ltd, Journal of Nursing Management, 15, 188–196
Srivastva 1987), to identify and replicate the conditions
in which processes of care result in favourable outcomes.
Studying the relationship between human resources and
outcomes without explicating the underlying nursing
care processes assumes that care was delivered, but does
not capture the nature, quality and safety of the care
actually given to patients (Meyer & Massagli 2001).
Examples of nursing process studies can be found in
symptom management research in cancer care. While
this area has been recognized as a priority for cancer
nursing research (McIlfatrick et al. 2004), most of the
research has focused on describing symptom experience
and its relationship to processes of care has not been
examined (Richardson et al. 2002). Nursing adminis-
tration research also needs to explore how processes of
care affect such nurse outcome measures as job satis-
faction and retention. Case management programmes
and studies of the primary care model of nursing care
delivery with the oncology population have shown
some impact of nursing processes on clinical and
financial outcome measures (Haddock et al. 1997).
These models promote interdisciplinary collaboration
to support patients and their families navigate the
health care system.
Linking health care needs, nursing care
processes and resources
The previous sections presented the concepts of health
care needs, nursing care processes and resources and
their individual impact on outcomes. Adopting a sys-
tems perspective in nursing administration research
requires an examination of the interplay between health
care needs, nursing resources and processes of care.
A review of studies that explored the relationship
between patient health care needs and processes of care
suggested that little attention has been paid to this issue.
Health care needs have been the catalyst for instituting
changes in processes of care delivery, but the impacts of
these changes have rarely been documented. In cancer
care, Koinberg et al. (2002) reported that the imple-
mentation of a follow-up nursing visit with breast
cancer patients in response to patient identified needs
was associated with an increase in patient satisfaction.
In a randomized trial that examined the impact of
changes in processes of care on the health care needs of
patient with lung cancer, Moore et al. (2002) found
that patients who received a nurse-led follow-up visit
rated their dyspnoea as less severe, had better scores for
emotional functioning, and were more satisfied with the
organization of care, information received and personal
care experience than the usual care group.

There is also a reciprocal relationship between nur-
sing care processes and resources, and a number of
studies have documented how the reduction in
resources has affected how nursing care is delivered. One
consistent result has been the delegation of nursing care
activities to less skilled workers (Grando 1998, Bazzoli
et al. 2002). When cost containment is the primary
objective, these results can be appealing (Porter 1995).
When other outcomes are considered, the interpretation
of these data becomes more complex. For example, in
the cancer context, the shift from inpatient to outpatient
settings and the decrease in the number of dedicated
oncology inpatient units was originally initiated to re-
duce costs associated with hospitalization. However, it
also meant that hospitalized patients were more acutely
ill, had more symptom management problems or were
dealing with life-threatening disease. This increased the
demand for additional nursing human resources and
added to the workload of individual nurses.
Nursing administration research also needs to explore
the fit between the adequacy of resources and changing
patient health care needs. The ability of nursing care
services to meet health needs is influenced by the bal-
ance in the supply, distribution and scope of practice of
health care professionals. It is difficult for nurse
administrators to locally adapt nursing resources to the
patient health care needs because of existing national
policies on these issues. The resources required at the
national and regional levels is carried out through
health human resource planning (HHR) exercises which
determine the number, mix and distribution of health
providers required to meet population health care needs
at some identified future point in time (O’Brien-Pallas
et al. 2001b). In Canada, this exercise has proven to be
challenging because of the difficulty in obtaining data
on workforce numbers in cancer care (Padmos 2002).
Vacancies, work life issues and supply factors, such as
training programme intakes and immigration limit the
validity of such planning exercises. Moreover, future
patient health care needs in cancer care are not well
established, which makes nursing human resources
prediction even more difficult. In this regard, a Cana-
dian task force in cancer care has formulated two rec-
ommendations (Padmos 2002). The first, is the creation
of an inventory of oncology patient care needs that
would enable administrators to identify the appropriate
care providers and the basic and advanced nursing skills
that are required. The second, is the creation and
national registry of nurses and other health professionals
in oncology that would support the critical exercise of
HHR planning from both a national and a regional
perspective. This would give nursing administrators the
ª 2007 The Authors. Journal compilation ª 2007 Blackwell Publishing Ltd, Journal of Nursing Management, 15, 188–196
Nursing administration
capacity to match nursing human resources needs with
the health care needs of the patients and is one example
of the attempt to create links between policy-makers,
health care organizations and nurse administrators in
order to plan the actual and future requirements in
nursing human resources for a specific population.
One important aspect of the relationship between
health care needs and processes of care is the notion of
organizational change. How changes are brought
about within health care organizations is complex and
environmental factors play a key role. It could be
argued that because nursing care occurs within a
medically driven health care organization, it is the
organization itself that will determine what patient
health care needs will be addressed and the unique
political, social and economic circumstances in which
nursing administrative decisions must be made.
Effective health care organizations are those that bal-
ance the relationships between human resources, nur-
sing processes and patient needs with the constraints of
their unique environment. Effective nursing manage-
ment requires individuals who understand nursing’s
unique contribution in the system, and not only
respond to the needs of the environment but also are
active in shaping it.
The future
In an era where administrators are expected to make
decisions based on the best available evidence, the
development of nursing administration specific know-
ledge is essential to improving outcomes for patients,
for care providers and for the effective functioning of
the health care system. This conceptual framework
provides nurse administrators and researchers a frame-
work for situating knowledge that is currently available.
When care reform is everywhere on the agenda, nursing
administrators need to identify the relationships
between health care needs, nursing resources, processes
of care and outcomes at all levels. Understanding these
relationships is critical to informed decision-making in a
changing health care system.
This framework also provides a road map for the
development of new studies in nursing administration
research. Using the example of cancer care, each of the
dimensions presented in this study helped to organize
current knowledge and to identify where the develop-
ment of evidence is required. This approach provides an
argument for the development of programmes of
research to demonstrate the nature of the links between
nursing and patient outcomes, rather than continuing to
present isolated descriptive results from small-scale
193
A. D. Biron et al.
studies (Richardson et al. 2002) that focus on selected
components presented. Issues addressed by such pro-
grammes of research would best be determined by
researchers and administrators working in collabor-
ation. Nurse administrators should not only be involved
in the problem definition but also at every step of the
research process. Collaborative research ensures that
the needs of administrators are considered in the
selection of pertinent research questions, and increases
the probability that the research will have a direct
relevance to nursing services.
Changes in effectiveness and efficiency of an organ-
ization that result from evidence-based administrative
decisions are of primary importance to stakeholders,
including research funding agencies who support nur-
sing administration research. More programmes to
support nursing administration researchers are needed.
While initiatives have been implemented to recruit
researchers to nursing administration and to create
avenues for the sharing of expertise and providing
financial support (Canadian Health Services Research
Foundation 2005, Ferasi 2005), it will require concerted
efforts to increase the capacity for nursing administra-
tion research.
The model presented here is specific enough to focus
on the practice and research of nursing administration
not only in cancer care but also in other clinical
populations. It is likely that there are similarities in
nursing administration problems that are common
across populations and the use of such framework
would help make the commonalities more evident.
In addition, the systemic perspective proposed in the
framework helps administrators maintain a global
perspective that will enable them to make the best fit
between the evidence and their individual health care
organization.
Acknowledgements
Alain Biron and Marie-Claire Richer would like to thank the
Center for training and expertise in nursing administration
research (FERASI), the research foundation of the McGill
University Health Centre (THP Molson Award) and the
Fonds de la Recherche en Santé du Québec (FRSQ) for their
support.
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