nursing care delivery

Staffing and Nursing Care Delivery Models

Key Concepts

Staffing for health care organizations Patient classification systems Nursing care delivery models Critical pathways Nursing case management

Staffing

Activities to ensure an adequate number and mix of team members

Staffing considerations Patient needs Staff satisfaction Organizational needs

Meeting Patient Needs

Primary considerations Number of patients Intensity of care required Staff experience and preparation

Patient classification systems/acuity level Categorize patients according to care needs

Classification System Considerations Age and functional ability Communication skills Cultural and linguistic diversities Severity/urgency of the admitting condition Scheduled procedures Ability to meet health care requisites Availability of social supports Other specific needs

(Recommended by the American Nurses Association)

Meeting Staff Needs

Satisfied nurses provide higher quality, more cost-effective care

24 hour/day, 365 day/year staffing needs create staffing challenges Creative staffing options Staff input about staffing

Meeting Organizational Needs

Budget and financial management Number of staff Staff mix

Licensing and accreditation Customer satisfaction Quality care

The Number One Challenge

Appropriate staffing within budget constraints with well-trained, competent, professional staff members who are committed to providing safe, high-quality care

Nursing Care Delivery Models

Detail assignments, responsibility, and authority to accomplish patient care

Determine who is going to perform what tasks, who is responsible, and who makes decisions

Match number and type of caregivers to patient care needs

Classic Nursing Care Models

Total patient care Functional nursing Team nursing Primary nursing Variations have been adopted to improve

care

Total Patient Care

Nurse is responsible for planning, organizing, and performing all care

Oldest method of organizing patient care Typically performed by nursing students Common use areas—intensive care unit

(ICU) and postanesthetic care unit (PACU)

Total Patient Care—cont’d

Advantages High degree of autonomy Lines of responsibility and accountability are

clear Patient receives holistic, unfragmented care

Disadvantages Each RN may have a different approach to care Not cost-effective Lack of RN availability

Patient CareThe registered nurse plans, organizes, and performs all care

Registered Nurse

8-hour shift

Registered Nurse

8-hour shift

Registered Nurse

8-hour shift

Total Patient Care (Case Method) Delivery

Functional Nursing

Staff members assigned to complete specific tasks for a group of patients

Evolved during World War II as a result of a nursing shortage

Unskilled workers trained to perform routine, simple tasks

Common use area—operating room

Functional Nursing—cont’d

Advantages Care is provided economically and efficiently Minimum number of RNs required Tasks are completed quickly

Disadvantages Care may be fragmented Patient may be confused with many care

providers Caregivers feel unchallenged

Nurse Manager

LPNPO Meds

Treatments

RNAssessmentsCare Plans

Nurse AideVital signsHygiene

Nurse AideHygieneStocking

Assigned Patient Group

Functional Nursing Care Delivery Model

Team Nursing

RN as team leader coordinates care for a group of patients

Evolved in the 1950s to improve patient satisfaction

Goal was to reduce fragmented care Common use areas—most inpatient and

outpatient areas

Team Nursing—cont’d

Advantages High-quality, comprehensive care with a high

proportion of ancillary staff Team members participate in decision making

and contribute their own expertise Disadvantages

Continuity suffers if daily team assignments vary

Team leader must have good leadership skills Insufficient time for planning and

communication

Nurse Manager

RN Team LeaderRN

LPNs/LVNsNursing Assistants

RN Team LeaderRN

LPNs/LVNsNursing Assistants

Assigned Patient Group Assigned Patient Group

Team Nursing Model

Modular Nursing

Modification of team nursing Patient unit is divided into modules or units

with an RN as team leader The same team of caregivers is assigned

consistently to the same geographic area Concept evolved to increase RN

involvement in care

Modular Nursing—cont’d

Advantages Continuity of care is improved RN more involved in planning and coordinating

care Geographic closeness and efficient

communication Disadvantages

Increased costs to stock each module Long corridors not conducive to modular

nursing

GeographicPatient UnitPatient Care

Team: RNs

LPNs/LVNsNurse Aides

MedsSuppliesLinens

GeographicPatient UnitPatient Care

Team: RNs

LPNs/LVNsNurse Aides

MedsSuppliesLinens

GeographicPatient UnitPatient Care

Team: RNs

LPNs/LVNsNurse Aides

MedsSuppliesLinens

Nurse Manager

Modular Nursing Model

Primary Nursing

RN “primary nurse” assumes 24-hour responsibility for planning, directing, and evaluating care

Evolved in the 1970s to improve RN autonomy

Common use areas—hospice, home health, and long-term care settings

Primary Nursing—cont’d

Advantages High-quality, holistic patient care Establish rapport with patient RN feels challenged and rewarded

Disadvantages Primary nurse must be able to practice with a

high degree of responsibility and autonomy RN must accept 24-hour responsibility More RNs needed; not cost-effective

Primary Nurse 24-hour responsibility for

planning, directing & evaluating patient care

Patient

Associate Nurses

Provide care when primary

nurse is off duty

Physician and other members

of the health care team

Primary Nursing Model

Partnership Model (Co-Primary Nursing)

RN is partnered with an licensed practical nurse/licensed vocational nurse (LPN/LVN) or nursing assistant to work together consistently

Modification of primary nursing to make more efficient use of the RN

Partnership Model (Co-Primary Nursing)—cont’d Advantages

More cost-effective than primary nursing RN can encourage training and growth of

partner Disadvantages

RN may have difficulty delegating to partner Consistent partnerships difficult to maintain

due to varied schedules

Patient-Centered Care(Patient-Focused Care) Cross-functional teams of professionals and

assistive personnel work together as a unit-based team

Recent development in nursing care delivery models

More patient oriented than department oriented

Models vary considerably among facilities

Patient-Centered Care(Patient-Focused Care)—cont’d Advantages

Patient comes into contact with fewer workers Workers are unit based and spend more time

in direct-care activities Team is supervised by an RN RN is accountable for a wide range of services

and functions at a higher level Cost-effective

Patient-Centered Care(Patient-Focused Care)—cont’d Disadvantages

Major change in organizational structure is required

Departments other than nursing must be willing to accept nursing leadership

Nurse manager supervises many types of workers

Nurse Manager

Patient

Patient Care Respiratory Services Patient TransportationHousekeeping ECG Admission/Discharge PhlebotomyPhysical/Occupational/Speech Therapy Dietary ServicesFinancial Counseling Supply Management

Patient-Centered Care Model

Case Management

First introduced in the 1970s by insurance companies

Hospitals adopted the model in the 1980s Value demonstrated through research Components include:

Assessment, planning, implementation, evaluation, and interaction

Case Management—cont’d

Variations are found in most health care organizations

Reserved for chronically ill patients, seriously ill patients, or long-term, expensive cases

RN assumes a planning and evaluative role; usually not responsible for direct-care duties

Supplemental form of care delivery; does not replace direct-care model

RN Case Manager

Coordinates the patient’s care throughout the course of an illness from a payer or facility perspective Employee of the payer (external case

management) Employee of the health care facility (internal case

management)

NURSE CASE MANAGERAssesses, plans, implements, coordinates,

monitors, and evaluates patient care options and services to meet health needs

Onset of Illness

Resolution of Illness

Collaborates with Nursing, Physicians, Physical/Speech/

Occupational Therapists, Dietary, and Ancillary Services

Collaborates With Patient and Family

Coordinates Services:Home Care, Hospice,

Extended /Long-term CareAmbulatory Care Services

Nursing Case Management Model

Clinical Pathways

Delineate a predetermined written plan of care for a particular health problem

Specify desired outcomes and transdisciplinary intervention

Address a common medical diagnosis Dictate the type and amount of care given

and thus have financial implications

Clinical PathwaysTerminology

Patient outcomes Transdisciplinary intervention Variance Trigger

Clinical PathwaysEssential Components

Consults Laboratory and

diagnostic tests Treatments Medications Safety

Self-care activities Nutrition Patient and family

education Discharge planning Triggers

Choosing a Nursing Care Delivery Model What staff mix is required? Who should make work assignments? Work assigned by task? By patient? How will communication be handled? Who will make decisions? Who will be responsible and accountable? Fit with unit/facility/organization management?

Influences on Nursing Care Delivery Model Selection Health care setting

Acute care, long-term care, ambulatory care, home care, and hospice

Organizational structure and resources Management, staffing, supplies, and physical

layout Patient needs

Acute, long-term, and chronic

Evaluation of Nursing Care Delivery Models

Timely, cost-effective outcomes achieved?

Patient and families happy with care? Team members satisfied with care? Good communication among all team

members? RNs utilized and challenged

appropriately?