Care Delivery Strategies

Care Delivery Strategies

Susan Sportsman


A nursing care delivery model is the method used to provide care to patients. Because nursing care is viewed by some as a cost rather than a source of revenue, it is logical for institutions to evaluate their method of providing patient care for the purpose of saving money while still providing quality care. In this chapter, various models of nursing care delivery are discussed, including case method (total patient care); functional nursing; team nursing; primary nursing including hybrid forms; and nursing case management. In addition, the influence of disease-management programs, differentiated nursing practice, and “Transforming Care at the Bedside” is introduced.

Each nursing care delivery model has advantages and disadvantages, and none is ideal. Some methods are conducive to large institutions, whereas other systems may work better in smaller community settings. Managers in any organization must examine the organizational goals, the unit objectives, patient population, staff availability, and the budget when selecting a care delivery model. This historical overview of the common care models is designed to convey the complexity of how care is delivered. This perspective is important because each of these approaches is still used within the broad range of healthcare organizations. In addition, these models often serve as the foundation for new innovative care delivery models.

Case Method (Total Patient Care)

The case method, or total patient care method, of nursing care delivery is the oldest method of providing care to a patient. This model should not be confused with nursing case management, which is introduced later in the chapter.

The premise of the case method is that one nurse provides total care for one patient during the entire work period. This method was used in the era of Florence Nightingale when patients received total care in the home. Today, total patient care is used in critical care settings where one nurse provides total care to one or two critically ill patients. Nurse educators often select this method of care when students are caring for patients. Variations of the case method exist, and it is possible to identify similarities after reviewing other methods of patient care delivery described later in this chapter.

Model Analysis

During an 8- or 12-hour shift, the patient receives consistent care from one nurse. The nurse, patient, and family usually trust one another and can work together toward specific goals. Usually, the care is patient-centered, comprehensive, continuous, and holistic. But the nurse may choose to deliver this care with a task orientation that negates the holistic perspective (Tiedeman & Lookinland, 2004). Because the nurse is with the patient during most of the shift, even subtle changes in the patient’s status are easily noticed (Figure 13-1).

In today’s costly healthcare economy, total patient care provided by a registered nurse (RN) is very expensive. Is it realistic to use the highly skilled and extremely knowledgeable professional nurse to provide all the care required in a unit that may have 20 to 30 patients? Who oversees the care coordination in a 24-hour period (Tiedeman & Lookinland, 2004)? In times of nursing shortages, there may not be enough resources or nurses to use this model.

Staff RN’s Role

In the case method, the staff RN provides holistic care to a group of patients during a defined work time. The physical, emotional, and technical aspects of care are the responsibility of the assigned RN. This model is especially useful in the care of complex patients who need active symptom management provided by an RN, such as the care of the patient in a hospice setting or an intensive care unit. This care delivery model requires the nurse who is assigned to total patient care to complete the complex functions of care, such as assessment and teaching the patient and family, as well as the less complex functional aspects of care, such as personal hygiene. Some nurses find satisfaction with this model of care because no aspect of nursing care is delegated to another, thus eliminating the need for supervision of others (Tiedeman & Lookinland, 2004).

Functional Nursing

The functional model of nursing care delivery became popular during World War II when there was a severe shortage of nurses in the United States. Many nurses joined the armed forces to care for the soldiers. To provide care to patients at home, hospitals began to increase the number of LPNs/LVNs and unlicensed assistive personnel.

The functional model of nursing is a method of providing patient care by which each licensed and unlicensed staff member performs specific tasks for a large group of patients. These tasks are in part determined by the scope of practice defined for each type of caregiver. For example, the RN must be responsible for all assessments, although the LPN/LVN and UAPs may collect data that can be used in the assessment. Regarding treatments, an RN may administer all intravenous (IV) medications and do admissions, one LPN/LVN may provide treatments, another LPN/LVN may give all oral medications, one assistant may do all hygiene tasks, and another assistant may take all vital signs (Figure 13-2). This division of aspects of care is similar to the assembly line system used by manufacturing industries. Just as an auto worker becomes an expert in attaching fenders to a new vehicle, the staff nurse becomes expert in the tasks expected in functional nursing. A charge nurse coordinates care and assignments and may ultimately be the only person familiar with all the needs of any individual patient.

Model Analysis

There are several advantages to this model of patient care delivery. First, each person becomes efficient at specific tasks, and much work can be done in a short time. Another advantage is that unskilled workers can be trained to perform one or two specific tasks very well. The organization benefits financially from this model because care can be delivered to a large number of patients by mixing staff with a fixed number of RNs and a larger number of UAPs.

Although financial savings may be the impetus for organizations to choose the functional system of delivering care, the disadvantages may outweigh the savings (Figure 13-3). A major disadvantage is the fragmentation of care. The physical and technical aspects of care may be met, but the psychological and spiritual needs may be overlooked. Patients become confused with so many different care providers per shift. These different staff members may be so busy with their assigned tasks that they may not have time to communicate with each other about the patient’s progress. Because no one care provider sees patient care from beginning to end, the patient’s response to care is difficult to assess. Critical changes in patient status may go unnoticed. Fragmented care and ineffective communication can lead to patient and family dissatisfaction and frustration. Exercise 13-2 provides an opportunity to imagine how a patient would react to the functional method and also to imagine how the nurse may feel.

Nurse Manager’s Role

In the functional model of nursing, the nurse manager must be sensitive to the quality of patient care delivered and the institution’s budgetary constraints. Because staff members are responsible only for their specific task, the role of achieving patient outcomes becomes the nurse manager’s responsibility.

Staff members can view this system as autocratic and may become discontented with the lack of opportunity for input. By using effective management and leadership skills, the nurse manager can improve the staff’s perception of their lack of independence. The manager can rotate assignments among staff within legal and organizational contexts to alleviate boredom with repetition. Staff meetings should be conducted frequently. This encourages staff to express concerns and empowers them with the ability to communicate about patient care and unit functions.

Staff RN’s Role

The staff RN becomes skilled at the tasks that are usually assigned by the charge nurse. Clearly defined policies and procedures are used to complete the physical aspects of care in an efficient and economical manner. However, the functional model of nursing may leave the professional nurse feeling frustrated because of the task-oriented role. Nurses are educated to care for the patient holistically, and providing only a fragment of care to a patient may result in unmet personal and professional expectations of nurses.

The functional method of delivering care works well in emergency and disaster situations. Each care provider knows the expectations of the assigned role and completes the tasks quickly and efficiently. Subacute care agencies, extended-care facilities, and ambulatory clinics often use the functional model to deliver care quictly.

Team Nursing

After World War II, the nursing shortage continued. Many female nurses who were in the military came home to marry and have children instead of returning to the workforce. Because the functional model received criticism, a new system of team nursing (a modification of functional nursing) was devised to improve patient satisfaction. “Care through others” became the hallmark of team nursing. This type of nursing care delivery remains in use, particularly when reduced reimbursement and nursing shortages have resulted in organizations changing the staff mix and increasing the ratio of unlicensed to licensed personnel.

In team nursing, a team leader is responsible for coordinating a group of licensed and unlicensed personnel to provide patient care to a small group of patients. The team leader should be a highly skilled leader, manager, and practitioner, who assigns each member specific responsibilities according to role, licensure, education, ability, and the complexity of the care required. The members of the team report directly to the team leader, who then reports to the charge nurse or unit manager (Figure 13-4). There are several teams per unit, and patient assignments are made by each team leader.

FIGURE 13-4 Team nursing.

Model Analysis

Some advantages of the team method, particularly when compared with the functional approach, are improved patient satisfaction, organizational decision making occurring at lower levels, and cost-effectiveness for the agency. Many institutions and community health agencies currently use the team nursing method. Inpatient facilities may view team nursing as a cost-effective system because it works with an expected ratio of unlicensed to licensed personnel. Thus the organization has greater numbers of personnel for a designated amount of money.

The team method of patient care delivery has one major disadvantage, which arises if the team leader has poor leadership skills. The team leader must have excellent communication skills, delegation and conflict management abilities, strong clinical skills, and effective decision-making abilities to provide a working “team” environment for the members. The team leader must be sensitive to the needs of the patient and, at the same time, attentive to the needs of the staff providing the direct care (Moore, 2004). When the team leader is not prepared for this role, the team method becomes a miniature version of the functional method and the potential for fragmentation of care is high.

Nurse Manager’s Role

The nurse manager, charge nurse, and team leaders must have management skills to effectively implement the team nursing method of patient care delivery. In addition, the nurse manager must determine which RNs are skilled and interested in becoming a charge nurse or team leader. Because the basic education of baccalaureate-prepared RNs emphasizes critical-thinking and leadership concepts, they are likely candidates for such roles. The nurse manager should also provide an adequate staff mix and orient team members to the team nursing system by providing continuing education about leadership, management techniques, delegation, and team interaction (see Chapters 1, 3, 4, 18, and 26). By addressing these factors, the manager is aiding the teams to function optimally.

The charge nurse functions as a liaison between the team leaders and other healthcare providers, because nurse managers are often responsible for more than one unit and/or have other managerial responsibilities that take them away from the unit. The charge nurse provides support for the teams on a shift-by-shift basis. Appropriate support requires the charge nurse to encourage each team to solve its problems independently.

The team leader plans the care, delegates the work, and follows up with members to evaluate the quality of care for the patients assigned to their team. In the ideal circumstance, the team leader updates the nursing care plans and facilitates patient care conferences. Time constraints during the shift may prevent scheduling daily patient care conferences or prevent some team members attending those that are held.

The team leader must also face the challenge of changing team membership on a daily basis. Diverse work schedules and nursing staff shortages may result in daily changes in the staff mix of a team and a daily assignment change for team members. The team leader assigns the professional, technical, and ancillary personnel to the type of patient care they are prepared to deliver. Therefore the team leader must be knowledgeable about the legal and organizational limits of each role.

Primary Nursing

A cultural revolution occurred in the United States during the 1960s. The revolution emphasized individual rights and independence from existing societal restrictions. This revolution also influenced the nursing profession, because nurses were becoming dissatisfied with their lack of autonomy. In addition, the hierarchical nature of communication in team nursing caused further frustration. Institutions were also aware of the declining quality of patient care. The search for autonomy and quality care led to the primary nursing system of patient care delivery as a method to increase RN accountability for patient outcomes.

Primary nursing, an adaptation of the case method, was developed by Marie Manthey as a method for organizing patient care delivery in which one RN functions autonomously as the patient’s primary nurse throughout the hospital stay (Manthey, Ciske, Robertson, & Harris, 1970).

Primary nursing brought the nurse back to direct patient care. The primary nurse is accountable for the patients’ care 24 hours a day from admission through discharge. Conceptually, primary nursing care provides the patient and the family with coordinated, comprehensive, continuous care (Tiedeman & Lookinland, 2004). Care is organized, using the nursing process. The primary nurse collaborates, communicates, and coordinates all aspects of patient care with other nurses as well as other disciplines (Tiedeman & Lookinland, 2004). Advocacy and assertiveness are desirable leadership attributes for this care delivery model.

The primary nurse, preferably at least baccalaureate-prepared, is held accountable for meeting outcome criteria and communicating with all other healthcare providers about the patient (Figure 13-5). For example, a patient is admitted to a medical unit with pulmonary edema. His primary nurse admits him and then provides a written plan of care. When his primary nurse is not working, an associate nurse implements the plan. The associate nurse is an RN who has been delegated to provide care to the patient according to the primary nurse’s specification. If the patient develops additional complications, the associate nurse notifies the primary nurse, who has 24-hour accountability and responsibility. The associate nurse provides input to the patient’s plan of care, and the primary nurse makes the appropriate alterations.

FIGURE 13-5 Primary nursing.

Model Analysis

Tiedeman and Lookinland (2004) cited numerous works that speak to the quality of care and patient satisfaction with primary care. Some studies cited in their work speak to increased quality of care and patient satisfaction, whereas others find no difference in these parameters when compared with team nursing. RNs practicing primary nursing must possess a broad knowledge base and have highly developed nursing skills. In this system of care delivery, professionalism is promoted. Nurses experience job satisfaction because they can use their education to provide holistic and autonomous care for the patient. This high level of accountability for patient outcomes encourages RNs to further their knowledge and refine skills to provide optimal patient care. If the primary nurse is not motivated or feels unqualified to provide holistic care, job satisfaction may decrease.

In primary nursing, patients and families are typically satisfied with the care they receive, because they establish a relationship with the primary nurse and identify the caregiver as “their nurse.” Because the patient’s primary nurse communicates the plan of care, the patient can move away from the sick role and begin to participate in his or her own recovery. By considering the sociocultural, psychological, and physical needs of the patient and family, the primary nurse can plan the most appropriate care with and for the patient and family.

A professional advantage to the primary nursing method is a decrease in the number of unlicensed personnel. The ideal primary nursing system requires an all-RN staff. The RN can provide total care to the patient, from bed baths to patient education, even both at the same time! Unlicensed personnel are not qualified to provide this level of inclusive care (Figure 13-6).

A disadvantage of the primary nursing method is that the RN may not have the experience or educational background to provide total care. The agency needs to educate staff for an adequate transition from the previous role to the primary role. In addition, one has to ask whether the RN is ready and willing and capable of handling the 24-hour responsibility for patient care. In addition, the nurse practice acts must be evaluated to determine whether primary nurses can be held accountable when they are not physically present.

In times of nursing shortage, primary nursing may not be the model of choice. This model will not be effective if a unit has a large number of part-time RNs who are not available to assume the primary nurse role (24-hour responsibility). In addition, with the arrival of managed care in the 1990s, patients’ hospital stays were shorter than in the 1970s, when primary nursing became popular. Expedited stays make it challenging for primary nurses to adequately provide the depth of care required by primary nursing. If the patient is admitted on Monday and discharged on Wednesday, the primary nurse has a difficult time meeting all patient needs before discharge if he or she is not working on Tuesday. The primary nurse must rely heavily on feedback from associates, which defeats the purpose of primary nursing. In addition, the reduction in reimbursement to hospitals and other organizations associated with managed care caused administrators to consider ways to reduce the cost of care delivery. Because labor costs are the largest expense in care delivery and the nursing staff makes up the largest portion of the labor costs, attention was given to reducing these costs with changes in the model of care delivery.

Nurse Manager’s Role

The primary nursing system can be modified to meet patient, nursing, and budgetary demands while maintaining the positive components that spawned its conception. The nurse manager needs to determine the desire of staff to become primary nurses and then educate them accordingly. The associate nurses and all other healthcare providers need clearly defined roles. They also need to be aware of the primary nurse’s role and the importance of communicating concerns directly to that nurse.

The nurse manager who implements this care delivery model experiences some benefits. Primary nursing provides the nurse manager an opportunity to demonstrate leadership capabilities, clinical competencies, and teaching abilities to serve as a role model for professional practice. In addition, the roles of budget controller and unit quality manager remain. The traditional roles of delegation and decision making must be relinquished to the autonomous primary nurse. The nurse manager functions as a role model, advocate, coach, and consultant.

Staff RN’s Role

The primary nurse uses many facets of the professional role—caregiver, advocate, decision maker, teacher, collaborator, and manager. Because primary nurses cannot be present 24 hours a day, they must depend on associate nurses to provide care when they are not available. The associate nurse provides care using the plan of care developed by the primary nurse. Changes to the plan of care can be made by the associate nurse in collaboration with the primary nurse. This model provides consistency among nurses and shifts. To function effectively in this setting, staff nurses will need experience and opportunities to be mentored in this role.

Because it usually is not financially possible for an agency to employ only RNs, true primary nursing rarely exists. Some institutions have modified the primary nursing concept and implemented a partnership model to incorporate their current staff mix.

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Aug 7, 2016 | Posted by in NURSING | Comments Off on Care Delivery Strategies

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