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 Categorize patients according to care needs

Patient classification systems/acuity level

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 areasintensive care unit (ICU) and postanesthetic care unit (PACU)

Total Patient Carecontd

Advantages

High degree of autonomy Lines of responsibility and accountability are clear Patient receives holistic, unfragmented care Each RN may have a different approach to care Not cost-effective Lack of RN availability

Disadvantages

Registered Nurse
8-hour shift

Registered Nurse
8-hour shift

Registered Nurse
8-hour shift

Patient Care
The registered nurse plans, organizes, and performs all care

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 areaoperating room

Functional Nursingcontd

Advantages

Care is provided economically and efficiently Minimum number of RNs required Tasks are completed quickly
Care may be fragmented Patient may be confused with many care providers Caregivers feel unchallenged

Disadvantages

Nurse Manager

LPN/LVN
PO Meds Treatments

RN
Assessments Care Plans

Nurse Aide
Vital signs Hygiene

Nurse Aide
Hygiene Stocking

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 areasmost inpatient and outpatient areas

Team Nursingcontd

Advantages

High-quality, comprehensive care with a high proportion of ancillary staff Team members participate in decision making and contribute their own expertise
Continuity suffers if daily team assignments vary Team leader must have good leadership skills Insufficient time for planning and communication

Disadvantages

Nurse Manager

RN Team Leader RN LPNs/LVNs Nursing Assistants

RN Team Leader RN LPNs/LVNs Nursing 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 Nursingcontd

Advantages

Continuity of care is improved RN more involved in planning and coordinating care Geographic closeness and efficient communication
Increased costs to stock each module Long corridors not conducive to modular nursing

Disadvantages

Nurse Manager

Geographic Patient Unit

Patient Care Team: RNs LPNs/LVNs Nurse Aides Meds Supplies Linens

Geographic Patient Unit

Patient Care Team: RNs LPNs/LVNs Nurse Aides Meds Supplies Linens

Geographic Patient Unit

Patient Care Team: RNs LPNs/LVNs Nurse Aides Meds Supplies Linens

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 areashospice, home health, and long-term care settings

Primary Nursingcontd

Advantages

High-quality, holistic patient care Establish rapport with patient RN feels challenged and rewarded
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

Disadvantages

Primary Nurse
Physician and other members of the health care team

24-hour responsibility for planning, directing & evaluating patient care

Associate Nurses Provide care when primary nurse is off duty

Patient

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)contd

Advantages

More cost-effective than primary nursing RN can encourage training and growth of partner RN may have difficulty delegating to partner Consistent partnerships difficult to maintain due to varied schedules

Disadvantages

Patient-Centered Care (Patient-Focused Care)

Cross-functional teams of professionals and assistive personnel work together as a unitbased 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)contd

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)contd

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 Care Respiratory Services Patient Transportation Housekeeping ECG Admission/Discharge Phlebotomy Physical/Occupational/Speech Therapy Dietary Services Financial Counseling Supply Management

Patient

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 Managementcontd

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 patients 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)

Collaborates With Patient and Family

Onset of Illness

NURSE CASE MANAGER

Assesses, plans, implements, coordinates, monitors, and evaluates patient care options and services to meet health needs

Resolution of Illness

Collaborates with Nursing, Physicians, Physical/Speech/ Occupational Therapists, Dietary, and Ancillary Services

Coordinates Services: Home Care, Hospice, Extended /Long-term Care Ambulatory 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 Pathways Terminology

Patient outcomes Transdisciplinary intervention Variance Trigger

Clinical Pathways Essential 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 Management, staffing, supplies, and physical layout Acute, long-term, and chronic

Organizational structure and resources

Patient needs

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?