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Chapter 20

Staffing and Nursing


Care Delivery Models

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Staffing

Copyright 2014 by Mosby, an imprint of Elsevier Inc.

Definition

Activities required to ensure an adequate


number and mix of health care team members to
meet patient needs and provide safe, quality
care
Considerations are patient needs, staff
satisfaction, and organizational needs

Copyright 2014 by Mosby, an imprint of Elsevier Inc.

Staffing and Patient Needs

Research validates contribution of RNs to


improved patient outcomes and prevention of
premature mortality
Primary considerations for staffing a nursing unit

Number of patients
Intensity of care required
Staff experience and preparation
Geography of the environment
Available technology

Copyright 2014 by Mosby, an imprint of Elsevier Inc.

Staffing and Patient Needs (cont'd)

Patient classification systems

Categorize patients according to care needs


(acuity level)
Higher acuity levels mean that nursing care needs are
more intense

Copyright 2014 by Mosby, an imprint of Elsevier Inc.

Staffing and Patient Needs (cont'd)

ANA recommends that classification systems


should consider patients:
Age and functional ability
Communication skills
Cultural and linguistic diversities
Severity and urgency of the admitting condition
Scheduled procedures
Ability to meet health care requisites
Availability of social supports
Other specific needs identified by patient and RN

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Staffing and Patient Needs (cont'd)

Staff members must have the educational


preparation, skill, and experience necessary to
meet patient care needs
Concerns about inadequate numbers of
appropriately skilled and experienced staff
should be addressed with executive level
managers

Copyright 2014 by Mosby, an imprint of Elsevier Inc.

Staffing and Staff Satisfaction

Satisfied nurses generally provide higher quality,


more cost-effective care
24 hours/day, 365 days/year staffing needs make
meeting the nurses personal needs difficult
Creative staffing options are available to meet
varied needs of staff members
Methods to gain staff input about staffing and to
enhance autonomy are the key to staff satisfaction

Copyright 2014 by Mosby, an imprint of Elsevier Inc.

Staffing and Organizational Needs

Organizational needs affected by staffing include:

Efficient staff management ensures the organizations


financial solvency
Nurse manager accountable for budgetary guidelines for:

Financial resources
Licensing regulations and accreditation standards
Customer satisfaction

Numbers of staff working at any given time


Staff mix

RNs the most expensive staff; thus ratios for RNs to


other types of care providers may be established
Copyright 2014 by Mosby, an imprint of Elsevier Inc.

Staffing and Organizational Needs


(cont'd)

Licensing and accreditation agencies do not impose


mandatory staffing ratio but do look for evidence that
patients are adequately cared for
Customer satisfaction is critical to an organization's
success
A customers personal interaction with employees is
key to satisfaction

Nurse managers number one challenge:

Appropriate staffing within budget constraints with welltrained, competent, professional staff members who are
committed to providing safe, high-quality care
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Nursing Care Delivery Models

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Definition

Detail how task assignments, responsibility, and


authority are structured to accomplish patient
care
Describe which health care worker is going to
perform what tasks, who is responsible, and who
has the authority to make decisions
Basic premise is that the number and type of
caregivers are closely matched to patient care
needs in a cost-effective manner
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Classic Nursing Care


Delivery Models

Total patient care


Functional nursing
Team nursing
Primary nursing
Variations of these classics have been adopted
to improve quality and cost-effectiveness of
patient care

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Total Patient Care

Nurse is responsible for planning, organizing,


and performing all patient care during the
assigned shift
Background

Oldest method of organizing patient care, sometimes


referred to as case nursing
Nursing student typically performs total patient care
for assigned patients

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Total Patient Care (cont'd)

Advantages

RN maintains a high degree of practice autonomy


Lines of responsibility and accountability are clear
Patient receives holistic, unfragmented care
Communication at shift change is simple and direct

Disadvantage
Number of RNs required is very costly
Some tasks could be accomplished by a caregiver with less
training and at a lower cost
Nursing shortage will affect RN availability

Common use areas: intensive care units,


postanesthesia care units
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Functional Nursing

Staff members are assigned to complete certain


tasks for a group of patients rather than care for
specific patients

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Functional Nursing (cont'd)

Lines of responsibility and accountability

RN nurse manager assigns responsibility for


completion of tasks to a group of health care workers
RN is responsible for planning care and supervising
workers
RN retains accountability for the patient care provided

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Functional Nursing (cont'd)

Advantages of patient care

Disadvantages of patient care

Provided economically and efficiently


Minimum number of RNs required for patient care
Tasks completed quickly; little confusion about responsibilities
May be fragmented; possibility of overlooking priority patient
needs
Patient may feel confused because of many different care
providers
Caregivers may feel unchallenged when performing repetitive
functions

Common use areas: operating room


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Team Nursing

RN functions as a team leader and coordinates


care for a small group of patients

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Team Nursing (cont'd)

Lines of responsibility and accountability

RN team leader is responsible for the following:

Planning care
Assigning duties
Directing, supervising, and assisting team members
Giving direct care

RN retains accountability for all patient care


RN team leader is responsible for encouraging a
cooperative environment and maintaining clear
communication

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Team Nursing (cont'd)

Advantages

High-quality, comprehensive care can be provided with a


relatively high proportion of ancillary staff
Each member participates in decision making, problem solving
Each member contributes his/her own special expertise or skills

Disadvantages

Continuity of care may suffer with daily team assignments


Team leader may not have the leadership skills required to
effectively direct the team
Insufficient time for care planning and communication leads to
unclear goals and fragmented care

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Team Nursing (cont'd)

Common use areas: effective, efficient method


of patient care delivery that has been used in
most inpatient and outpatient health care
settings

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Modular Nursing

Modification of team nursing

Patient unit divided into modules; same team of


caregivers assigned consistently to same geographic
location
Each location or module has RN as team leader
Goal is to increase the involvement of the RN in
planning and coordinating care
Designated modules should contain all the supplies
needed by the staff to maximize efficiency

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Primary Nursing

RN primary nurse assumes 24-hour


responsibility for planning, directing, and
evaluating the patients care from admission
through discharge

Provides total patient care while on duty


While off duty, care is provided by an associate nurse,
who follows the care plan established by the primary
nurse

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Primary Nursing (cont'd)

Lines of responsibility and accountability

RN primary nurse has 24-hour responsibility and


accountability for patient care
Associate nurses are responsible for following the
plan of care
RN primary nurse is responsible for maintaining clear
communication among all members of the health care
team

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Primary Nursing (cont'd)

Advantages

Direct patient care provided by a small number of


nurses allows for high-quality, holistic patient care
Patient able to establish a rapport with the primary
nurse, and patient satisfaction is enhanced
Job satisfaction high because nurses are able to
practice with a high degree of autonomy and feel
challenged and rewarded

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Primary Nursing (cont'd)

Disadvantages

Implementation may be difficult because primary nurse is required


to practice with a high degree of responsibility and autonomy
Inadequately prepared primary nurse may not be able to make
the necessary clinical decisions or to communicate effectively with
the health care team
RN may not be willing to accept 24-hour responsibility as required
Number of RNs required for this method of care may not be costeffective and may be difficult to recruit and train

Common use areas: home health, hospice, long-term


care

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Partnership Model
(or Co-primary Nursing)

RN is partnered with an LPN/LVN or a nursing


assistant; pair work together consistently
Modification of primary nursing designed to
ensure more efficient use of RN
Lines of responsibility and accountability

RN responsible for planning care, assigning duties,


coordinating care, and supervising the partner
RN is accountable for patient care for all assigned
patients

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Partnership Model
(or Co-primary Nursing) (cont'd)

Advantages

More cost-effective than the primary care system


RN can encourage training and growth of partner

Disadvantages

RN may have difficulty delegating to the partner


Consistent partnerships are difficult to maintain on the
basis of varied staff schedules

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1. The nursing shortage escalates, and


certain geographic areas must institute
delivery models that require fewer
numbers of registered nurses. Which type
of nursing delivery models would be
appropriate?
Total patient care and primary nursing
B. Team nursing and functional nursing
C. Total patient care and functional nursing
D. Primary care and team nursing
A.

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Patient-Centered Care

Definition by IOM (2001)

Providing care that is respectful of and responsive to


individual patient preferences, needs, and values and
ensuring that patient values guide all clinical
decisions
Nurses, physicians, and other health professionals
partner with patients and families to ensure that
health care decisions respect patients wants, needs,
and preferences

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Patient-Centered Care (cont'd)

Philosophy of care

Not a typical nursing care delivery model but more a


philosophy of care
Should be incorporated as an essential component of
any nursing care delivery model

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Patient-Centered Care (cont'd)

Methods to engage patients, families, and


significant others as partners in care

Include them in developing care plans and discharge


plans
Include them in change-of-shift or hand-off reports
Provide them with the information and education
needed to make informed decisions
Establish family advisory councils to engage
patients and families in decision making

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2. A patient receives care for heart failure on a


nursing unit in which the interprofessional team
members including nurses, physicians, and
therapistsare committed to including the patient
and spouse in change of shift reports and to
seeking their input in all decisions affecting the
patients care. What type of care model is
represented in this unit?
A.Functional care
B.Primary care
C.Patient-centered care
D.Case management

Copyright 2014 by Mosby, an imprint of Elsevier Inc.

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Telehealth Nursing

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Characteristics

Important method of providing nursing care to


clients in ambulatory settings
Formally used to interact with patients,
beginning in the early 1970s
Also called telephone triage, telephone nursing,
or telehealth
Encompasses all telecommunication methods
e-mail, Internet, fax, and telephone

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Nurses Roles in Telehealth Nursing

Triage
Interventions
Consultation
Surveillance and follow-up

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Practice Standards
(Published by the American
Academy of Ambulatory Care
Nursing)

Using protocols, algorithms, or guidelines to


assess and address patient needs
Prioritizing the urgency of patient needs
Developing a collaborative plan of care
Evaluating outcomes of practice and care

Copyright 2014 by Mosby, an imprint of Elsevier Inc.

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Structure

Integral part of an outpatient clinic practice


Function of a centralized call center

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Future of Telehealth Nursing

Ever-increasing opportunities for nurses in


telehealth to influence the quality of care

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Case Management

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Evolution

Introduced in 1970s by insurance companies as a method


to monitor and control expensive health insurance claims
Today, most health insurance companies have a case
management program
By mid-1980s, hospitals recognized need for case
management to manage patients treatment plan and
length of stay because of the diagnosis-related group
(DRG) payment method
The RN case manager coordinates the patients care
throughout the course of an illness, as an employee of the
payer or as an employee of the health care facility

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Evolution (cont'd)

Goal of case management is to focus attention


on quality, outcomes, and cost of care, and to
assist the patient to move through the continuum
of care
Studies have demonstrated the value of case
management in improving patient outcomes and
reducing costs

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Definition

Collaborative approach to providing and


coordinating health care services, identifying
and facilitating options and services for meeting
health needs, decreasing fragmentation and
duplication of care, and enhancing quality, costeffective clinical outcomes
Nurse case manager manages a case load of
patients from preadmission (onset of illness) to
discharge (resolution of illness)

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Case Management in Health Care

Other disciplines, most notably social work, have


been involved in developing case management
programs
When clinical knowledge is required, the RN is
most effective in the case management role
Variations in case management are found in
almost all health care organizations

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Case Management and Other


Nursing Care Delivery Models

Supplemental form of nursing care that does not


replace the nursing care delivery model already
in place to provide direct patient care
RN case manager assumes a planning and
evaluative role and usually is not responsible for
direct care duties
Case management is generally reserved for the
chronically ill; the seriously ill or injured; and
long-term, high-cost cases
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Clinical Pathways
(Critical Paths, Practice Protocols,
Care Maps)

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Defining Features

Delineates a predetermined written plan of care for


a particular health problem
Specifies desired outcomes and the interdisciplinary
intervention required within a specified period for a
particular diagnosis or health problem
Written to address common medical diagnoses
such as heart failure and pneumonia, common
nursing care needs such as immobility, and medical
complications such as weaning from mechanical
ventilation

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Defining Features (cont'd)

Differ from clinical practice guidelines

Clinical pathways define key processes and patient


goals in the day-to-day management of care
Clinical practice guidelines guide broader decision
making and focus on decisions made in performing a
procedure or service

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Background

Developed to identify quality, cost-effective care


plans to reduce the patients length of stay in the
hospital
Dictate the type and amount of care given and
thus have financial implications for the health
care facility

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Terminology

Patient outcomes: result of intervention by the health


care team
Interdisciplinary intervention: collaborative effort by
all disciplines, along with the patient and family, to
reach desired health outcomes
Variance: any event that may alter the patients
progress through the clinical pathway
Trigger: alerts caregiver that an unexpected event
has occurred and identifies potential and actual
variations in patients response to a planned
intervention
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Essential Components of
Clinical Pathways

Consults
Laboratory and diagnostic tests
Treatments and medications
Safety and self-care activities
Nutrition
Patient and family education needs
Discharge planning
May address triggers
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Development of Clinical Pathways

Based on accepted standards of practice


Medical specialty boards developed clinical practice
guidelines
The Agency for Healthcare Research and Quality (AHRQ), in
conjunction with medical specialty associations, professional
societies, and other health care organizations, has developed
a series of clinical practice guidelines
Developed for the health care organizations most common or
costly diagnoses
A team supported by management, with representatives from
various disciplines such as nursing, medicine, therapy,
pharmacy, and dietary, develops clinical pathways
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Choosing a Nursing Care


Delivery Model

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Examples of Different Health Care


Settings Requiring Different Models

Emergency departments use functional nursing because


emphasis is on efficient assessment and immediate
treatment
Team nursing frequently used in medical-surgical units
Total patient care is common in critical care units
Home health agencies may use primary nursing
A study found that more than 50% of staff from 26
hospitals reported using two or three nursing care
delivery models, sometimes over the course of a single
shift (Kramer and Schmalenberg, 2005)

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Influences on the Type of Nursing


Care Delivery Model Used

Health care setting

Acute care
Long-term care
Ambulatory care
Home care and hospice

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Influences on the Type of Nursing


Care Delivery Model Used (cont'd)

Organizational structure and resources

Patient needs

Management structure
Staffing resources
Supply resources
Physical layout of the facility
Acute
Long-term/chronic

Staff availability, skills, and competencies


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Evaluation of Nursing Care


Delivery Models

Are patient outcomes achieved in a timely, costeffective manner?


Are patients and families happy with care?
Are physicians and other health team members
satisfied with care?
Does the system allow for implementation of the
nursing process?
Does the system facilitate communication
among all members of the health care team?
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Future Nursing Care Delivery


Models

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Factors Influencing Changes in


Nursing Care Delivery

Rapid technological advances


Fast-paced patient turnover in acute care settings
RNs value in patient safety and quality care
Ongoing shortages of nurses and other health
professionals
Strong focus on outcomes of care
Consumer demand for instant access to care and
information
Need to focus on the underlying determinants of health
that are affected by lifestyle and personal choice

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Nursing Now and in the Future

Traditional models of nursing care focused on


comprehensive knowledge of patient needs and
care provided over an extended period
Now, nurses may be assigned an entirely new
group of patients to care for every shift, or even
more than once during a shift
Nurses of the future must conduct focused
assessments and set priorities to resolve before
the patient is quickly transitioned to another level
of care
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Nursing Now and in the Future


(cont'd)

Nurses in outpatient and community-based settings are


challenged to address the following:

Patients demands for instant access to care and information


Patients need for support and education to address lifestyle and
personal choices that may affect their health

Relationship-based care must be considered in high-tech


fast-paced environments where care must be consistent
with nursing values of compassion, caring, and healing
Nurse leaders will be challenged to identify new models
that are cost-effective, will improve quality and safety of
care, and facilitate relationship-based nursing
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