nursing care delivery
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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?