Staffing and Nursing Care Delivery Models

Staffing and Nursing Care Delivery Models

Barbara Cherry, DNSc, MBA, RN, NEA-BC

Key Terms

Clinical pathway:

Clinical management plans that specify the optimal timing and sequencing of major patient care activities and interventions by the interprofessional team for a particular diagnosis, procedure, or health condition and are designed to standardize care delivery (Coffey et al, 2005); clinical pathways may also be called critical paths, practice protocols, or care maps; clinical pathways support the implementation of clinical practice guidelines.

Clinical practice guidelines:

Recommendations for appropriate treatment and care for specific clinical circumstances; guidelines are developed though a systematic process to integrate the best evidence for treating specific medical conditions and assist health care providers to make decisions about appropriate treatment (Institute of Medicine [IOM], 1990).

Nursing care delivery model:

Also called care delivery system or patient care delivery model; details the way work assignments, responsibility, and authority are structured to accomplish patient care; depicts which health care worker is going to perform what tasks, who is responsible, and who has the authority to make decisions.

Patient acuity:

Indication of the amount and complexity of care required for any particular patient; high acuity indicates a need for more intense, complex nursing care as compared with lower acuity, which indicates a need for moderate, less complex nursing care.

Patient classification system:

Method used to group or categorize patients according to specific criteria and care requirements and thus help quantify the patient acuity, or amount and level of nursing care needed.

Staff mix:

Combination of categories of workers employed to provide patient care (e.g., RNs, LPNs, or licensed vocational nurses [LVNs], or unlicensed assistive personnel [UAP]).


Ensuring that an adequate number and mix of health care team members (e.g., RNs, LPNs or LVNs, UAP, clerical support) are available to provide safe, quality patient care; usually a primary responsibility of the nurse manager.

Unlicensed assistive personnel (UAP):

An unlicensed individual who is trained to function in an assistive role to the RN by performing patient care activities as delegated by the nurse; may include nursing assistants, clinical assistants, orderlies, health aides, or other titles designated within the work setting.


Additional resources are available online at:


As a student nurse, John Knox noticed during rotations through the different clinical areas that the registered nurses (RNs) had various types of responsibilities and duties. On the medical-surgical units, RNs supervised a group of licensed practical nurses (LPNs) and nursing assistants who provided direct patient care, and the RNs performed patient assessments, care planning, and education. In the critical care unit, RNs provided all the care required by the patient with little help from any other caregivers. In the obstetric unit, two RNs worked as a team to provide care to laboring mothers. In the outpatient health clinic, each RN was assigned to perform specific tasks; one nurse was assigned to do all diabetic teaching, and another was assigned to triage all telephone calls from patients. Some of the clinical areas used a mostly RN staff, whereas other clinical units had a variety of staff, from RNs to nursing assistants. John had many questions about why care delivery was very different in the different clinical sites.

Chapter Overview

Of all the nurse manager’s varied and complex roles, staffing and assigning work is probably the most challenging and certainly the most important to the delivery of safe, quality patient care. Staffing ensures that an appropriate number and level of staff members are available to provide care; assigning is the method used to divide work tasks among the various staff members. This chapter presents a brief introduction to staffing and its surrounding issues, such as acuity levels and staff satisfaction. A description follows of various nursing care delivery models, which details how work assignments are structured. Also discussed are telehealth and case management as nursing care delivery models, in addition to the use of clinical pathways and clinical practice guidelines. The chapter attempts to answer the following questions related to staffing and nursing care delivery models:

Is the work assigned by task or by patient?


Staffing can be defined as the activities required to ensure that an adequate number and mix of health care team members (e.g., RNs, LVNs or LPNs, UAP, clerical support) are available to meet patient needs and provide safe, quality care. Important research is validating the contribution and value of RNs to improving patient outcomes, reducing complications and length of hospital stay, and preventing premature mortality (Blegen et al, 2011; Dall et al, 2009; Needleman et al, 2011). The Institute of Medicine’s report titled Keeping Patients Safe: Transforming the Work Environment of Nurses (2004) is an extensive analysis of nurses’ work environments and staffing issues; this report strongly affirms nurses’ essential roles in achieving quality patient care and safety. In order for nurses to have the greatest opportunity to achieve safe, quality care, staffing systems must address individual and aggregate patient care needs and the clinical competencies of nurses to provide care to specified patient populations; staffing systems must also reflect the value of RNs as vitally important to the organization and provide nurses time to exercise professional judgment, and acknowledge that patient needs can change from moment to moment (ANA, 2012). While appreciating the overall value of the RN in providing patient care, several specific considerations regarding staffing are reviewed related to (1) patient needs, (2) staff satisfaction, and (3) organizational needs.

Staffing and Patient Needs

The primary considerations for staffing a specific nursing unit are the number of patients; the level of intensity of care required by those patients (commonly referred to as patient acuity); contextual issues, such as architecture, geography of the environment, and available technology; level of preparation and experience of the staff members providing the care; and the quality of the nurses’ work life (ANA, 2005). Knowing only the number of patients that require care is an ineffective way to plan staffing because of the wide range of care requirements needed by individual patients. To account for the diverse care needs and quantify the intensity of care required by a group of patients, nurse managers responsible for staffing use various patient classification systems.

Patient Classification Systems

Patient classification systems group or categorize patients according to specific criteria and care needs and thus help quantify the amount and level of care needed. This may be referred to as the acuity level. The higher the acuity level, the more intense the patient’s nursing care needs. For example, patients may be grouped in such categories as “uncomplicated postpartum” or “ventilator dependent.” As the reader can easily visualize, these two groups of patients require very different levels and amounts of care and therefore are categorized at different acuity levels. Imagine the many different kinds of patients treated by a health care facility, and you can begin to picture the complexity of patient classification systems.

Because of this complexity and the differences in patient populations across different health care facilities, patient classification systems vary from organization to organization. However, the ANA (2005) has recommended that the following physical and psychosocial factors be considered when determining the intensity of care required for any group of patients:

Understanding the intensity of care required by individual patients and groups of patients based on these factors is the first step in developing effective patient classification systems and planning for appropriate staffing levels. The second step is knowing the level of preparation, skill, and experience of the staff members who are available to provide patient care.

Level of Staff Preparation and Experience

It is of critical importance that the staff members available to provide patient care have the educational preparation, skill, and experience necessary to meet patient care needs. Another consideration in staffing is the clinical competencies that are required to care for the population being served. The nurse who is responsible for making staffing decisions must be aware of each individual staff member’s educational level, competencies, experience, skill, and training. Ideally, clinical support from experienced RNs should be available to support and advance the skills of those RNs and other staff members with less experience. Unfortunately, this is not always possible in times of nursing shortages. If the nurse manager does not believe that adequate numbers of appropriately skilled and experienced staff members are available to provide safe patient care, the nurse should immediately address those concerns with his or her supervisor.

Staffing and Staff Satisfaction

Nurses who are satisfied with their work generally provide higher-quality, more cost-effective care. Staffing systems should address the quality of work life for the nursing staff as equally important as the quality of patient outcomes (ANA, 2005). Attention to staff schedules is a major responsibility for the nurse manager, especially in light of the 24-hour/day, 365-day/year staffing needs in many health care facilities. Creative staffing options are available to meet the varied needs of staff members, including the following:

Each of these options has various advantages and disadvantages. For example, long shifts over consecutive days may result in clinical errors when nurses become fatigued (Barker and Nussbaum, 2011; IOM, 2004). Self-scheduling is a popular staffing technique in which the responsibility for staffing the unit is delegated to the employees on the unit who work collectively to design the schedule based on preestablished staffing criteria and some guidance from the manager. No one scheduling system has proven to be best overall for staff satisfaction. However, staffing methods that gain staff input and enhance staff autonomy seem to be a major key to staff satisfaction (Wieck et al, 2009).

Staffing and Organizational Needs

The three basic organizational needs that are significantly affected by staffing are: (1) financial resources, (2) licensing regulations and The Joint Commission (TJC) or other accreditation standards, and (3) customer satisfaction.

Financial Resources

Productivity, the ratio of the amount of outputs produced (i.e., home visits) to the specific amount of input (nursing hours worked), is the measure of staffing efficiency. Because staff salaries are by far the largest expense for any health care organization, productivity—or the efficient use of staff—has a direct effect on the organization’s bottom line. Fortunately, even though RNs represent the highest-paid staff in a facility, research has yet again demonstrated the value of RNs in improving patient outcomes and increasing hospital profitability (Anderson et al, 2011; Dall et al, 2009; McCue et al, 2003). However, it is important to remember that most health care organizations continue to function under tight financial constraints, making efficient management of staff essential to ensure the organization’s financial solvency. The nurse manager is accountable for appropriately managing staffing to stay within budgetary guidelines for the following:

Customer Satisfaction

Perhaps most critical to an organization’s success in a competitive health care environment is customer (patient) satisfaction. The key to customer satisfaction is the patient’s personal interaction with the organization’s employees. According to Kenagy and associates (1999), “Interactions with patients and their families have remarkably strong effects on clinical outcomes, functional status and even physiologic measures of health” (p. 663). Appropriate staffing within budget constraints with well-trained, competent, professional staff members who are committed to providing safe, high-quality care is the number-one challenge for health care facilities.

This section has provided the reader with a brief introduction to staffing issues, such as scheduling options, patient classification systems, productivity and staff mix, and the RN’s contribution to improved patient outcomes. These issues related to staffing in a health care organization are much more complex than may appear from this introduction. The reader, especially the person interested in entering nursing management, is encouraged to learn more about staffing and these related issues. Box 20-1 lists online learning resources related to staffing.

Nursing Care Delivery Models

Nursing care delivery models, also called care delivery systems or patient care delivery models, detail the way task assignments, responsibility, and authority are structured to accomplish patient care. The nursing care delivery model describes which health care worker is going to perform what tasks, who is responsible, and who has the authority to make decisions. The basic premise of nursing care delivery models is that the number and type of caregivers are closely matched to patient care needs to provide safe, quality care in the most cost-effective manner possible.

The four classic nursing care delivery models used during the past five decades are: (1) total patient care, (2) functional nursing, (3) team nursing, and (4) primary nursing. Efforts to continually improve both the quality and cost-effectiveness of patient care have resulted in variations to these four classic models. Examples of variations include modular nursing and the partnership model (or coprimary nursing). Other types of nursing care models include patient-centered care, telehealth nursing, and case management. As the health care system continues to evolve in the twenty-first century with a focus on rapid patient turnover in acute care settings, extensive use of outpatient and community-based settings, and evidence of the RN’s valuable role in patient safety and improved outcomes, the need for new models of nursing care delivery is emerging. Thus considerations for future care delivery models also are presented.

Total Patient Care

The oldest method of organizing patient care is total patient care, sometimes referred to as case nursing. In total patient care, nurses are responsible for planning, organizing, and performing all care, including personal hygiene, medications, treatments, emotional support, and education required for their assigned group of patients during the assigned shift. A diagram of the total patient care model is shown in Figure 20-1.

Nov 6, 2016 | Posted by in NURSING | Comments Off on Staffing and Nursing Care Delivery Models
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