Running head: NURSING CARE MODELS 1

Nursing Care Models

Robin Ravenel

Chamberlain College of Nursing

NR447 – RN Collaborative Healthcare

April 2017
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Nurses have always been on the front lines of patient care, serving as important bridges and

change agents in healthcare practices. The practice of nursing has evolved from bed baths,

bandages, and medication administration, to include research, evidence-based practices, policies,

and so much more.

“Nursing includes the promotion of health, prevention of illness, and the care of ill,

disabled and dying people. Advocacy, promotion of a safe environment, research,

participation in shaping health policy and in patient and health systems management,

and education are also key nursing roles (International Council of Nurses, nd).”

For patients to obtain the best successful health outcomes, there must be a planned approach,

and an accountable team of healthcare members committed to its’ success. Any plan or design

requires a framework that helps to structure the plan, and guide the team. Frameworks vary

depending on the setting. As previously stated, nurses are change agents and utilize different

care models in delivering patient services. There are various nursing frameworks/models that

have been developed over the years to assist nurses providing safe quality care. Nursing care

models ultimately promote collaboration, self-management, well-being, and leadership. This

paper, will review and discuss the nursing care model observed in an ambulatory care setting at

Highlight Clinic.

Highlight Clinic is one of thirty (30) ambulatory care sites in a large hospital. The clinic’s

location is in an underserved community, with a diverse ethnic population. Services rendered

include primary care, pediatrics, obstetrics, gynecology, dermatology, endocrinology, and

psychiatry. Operating hours are Monday-Friday, 8am-5pm. On Thursday, clinic is open until
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7pm to provide care for teens and young adults. Clinic staffing includes a Practice

Administrator, five (5) registrars, ten (10) doctors, two (2) Nurse Practitioners (NPs), one

Registered Nurse (RN), five (5) Licensed Practical Nurses (LPNs), two (2) Patient Care

Technicians (PCTs), two (2) social workers, six (6) case managers, two (2) therapists, a

nutritionist, and phlebotomist. The practice is a great example of patient-centered care because

of the availability of services in one location.

Patients are warmly greeted by the registrars upon entering the clinic, and instructed to take a

number ticket for registration. Once registered the PCTs bring them in to the exam area to take

vital signs, conduct screening questions (i.e. pain, depression, smoking, and travel), and engage

them in conversation. Depending on the vital sign results, appearance of the patient and/or

answers to screening questions, the LPN meets with the patient for clarification of any of the

above, at which time the RN is also informed, and makes applicable decision of care. The RN is

responsible for daily schedule assignments, navigates patient flow, provides education to

patients/staff, coordinates care/services with other disciplines, and collaborates with stakeholders

when necessary. It was evident that the nursing staff were highly competent and secure in their

job functions. Communication between the RN, LPNs/PCTs, and support staff was mostly open

and uninhibited. For the most part, the clinic functioned in an orderly fashion. The LPNs were

observed as being confident and independent in their decision-making, empowered and well

supported by the RN. Only when faced with a sick patient, or complex problem, did they defer

to the captain, the RN, who guided and encouraged them in problem solving. Staff actions were

skillfully competent and well structured, and always the patient was the focal point.

This writer identified Team Nursing as the nursing care model being utilized.
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“Team Nursing consists of a registered nurse, licensed practical/vocational nurses,

and UAP. In this model the RN has a high level of autonomy and assumes the

centralized decision-making authority (Finkleman, 2016, p. 113).”

Registered serve as the command center in ambulatory care in the organization. This requires

them to be knowledgeable about many different areas, possess excellent verbal and written skills,

act as an ombudsman sometimes, and be effective change agent for patients and staff. There was

mutual respect for an individual’s job function, as well as, collaboration between disciplines.

“Effective teamwork contains the following dimensions: operative team structure, leadership,

situation monitoring, mutual support, and communication (Castner, Ceravolo, Foltz-Ramos, Wu,

2013).” The continuity of care was the key objective. In this setting the Team Nursing model

helped to ensure that patients did not get lost in the system. At each point of care, the patient

was engaged by a member of the nursing team. After being screened, patients are taken to the

doctor. Once they have completed their doctor/patient visit, the patient then sees the LPN before

being discharged to receive discharge instructions, medication, or printed results. This allows for

another opportunity to communicate with the patient, as well as, allowing the patient to ask any

questions, or seek further assistance from social workers.

“Nurses’ perceptions of team nursing have identified benefit for patient as being

continuity of care and delivery of safer and better quality care. For nurses the

benefits have been identified as improved working relationships; increased ability to

share and work together; availability of a shared network (Ferguson, L. and Cioffi, J,

nd)”.

As with any team, there are strong and weak links. This writer observed some weak links during

workflow that might have benefited a different approach or enhancing the role of the PCTs.
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Even though the system in place seem to work, there were times where the LPNs were

overwhelmed with patients waiting for vaccines, specimen collection instructions, and/or lab

results. This caused patients to become irritable due to the long waiting time. At these times the

Registered Nurse would do damage control, either by assisting the LPNs with their tasks, or

engaging very angry patients (who were not always so easy to please), leaving the nurse

vulnerable to much verbal abuse. During these moments, the PCT may have been able to assist

the LPN in providing some of the patient services. According to Finkleman, Care and Service

Team Models incorporate multiskilled workers, nurse extenders, and UAP (Finkleman, 2016, p.

112). Some healthcare roles have evolved due to finance, and streamlining services for

improved system processes. For example, in some institutions, Certified Nurse Assistants were

upgraded to PCTs or Medical Assistants, and given additional tasks that allow RNs and LPNs to

focus more on patient care and education. The clinic has also highlighted patient-centered care

through their Medical Home Model which utilizes the clinic’s case managers and navigators.

“In a recent survey reported in Health Affairs, patients with serious or chronic

illnesses around the world were surveyed and found that those being seen in primary

care practices that used elements of the patient-centered medical home felt their care

was more coordinated and reported fewer medical errors, (American Hospital

Association, 2012, p. 10)”.

The Highlight Clinic was a great setting to observe teamwork in action, but they did not just

work under a Team Nursing model. An Accountability-Based Primary Care Workforce Model

would be a better description of the clinic’s function.

“The design developed by the roundtable, the Accountability-Based Primary Care

Workforce Model, is a hub-and-spoke model, with the patient, family and healthy
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community at the center. Radiating out from this are different health care

professionals who each deliver care within their scope of practice and work

collaboratively in a team-based model (American Health Association, 2011).”

A great nursing team can be the key component in a patient thriving, and moving towards

their greatest well-being. However, there is no “I in team.” The best patient outcome requires a

team who is committed to the shared objective, which is a well and satisfied patient. For this to

occur, every member of the team must be accountable. When accountability exists, there is

increased quality of care, which translates into improved patient outcomes, increased patient

satisfaction, and a trusted and respected organization.

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References

American Hospital Association. (2011). Workforce roles in a redesigned primary care model.

Retrieved from http://www.aha.org/content/13/13-0110-wf-primary-care.pdf

American Hospital Association’s Physician Leadership Forum. (February, 2012, p. 10). Team-

based health care delivery: Lessons from the field. Retrieved from

http://www.ahaphysicianforum.org/files/pdf/team-delivery-report.pdf

Castner, J., Ceravolo, D. J., Foltz-Ramos, K., Wu, Y. B. (May 2013). The online journal of

issues in nursing: Nursing control over practice and teamwork. Retrieved from

http://www.nursingworld.org/MainMenuCategories/ANAMarketplace/ANAPeriodicals/OJIN/Ta

bleofContents/Vol-18-2013/No2-May-2013/Control-over-Practice-andTeamwork.html#Jcastner

Ferguson, L. and Cioffi, J. (nd). Australian journal of advanced nursing: Team nursing:

experiences of nurse managers in acute care settings. Retrieved from

http://www.ajan.com.au/Vol28/28-4_Ferguson.pdf

Finkelman, A. (2016, p. 112). Leadership and management for nurses: Core competencies for

quality care (3rd ed.). Boston, MA: Pearson. Retrieved from

https://online.vitalsource.com/#/books/9781323605547/cfi/6/86!/4/2/14/8/4@0:58.4

International Council of Nurses. Definition of nursing. Retrieved from

http://www.icn.ch/who-we-are/icn-definition-of-nursing/