3 Delivering Nursing Care

Learning Outcomes Describe how the delivery system structures nursing care. Describe what types of nursing care delivery systems exist. Discuss the positive and negative aspects of different systems.

Learning Outcomes Describe evolving types of delivery systems that have emerged. Explain characteristics of effective delivery systems.

Nursing Care Delivery Systems Provide structure for delivering care Delivery of care includes: Assessing care needs Formulating plan of care Implementing plan Evaluating patient's responses

Nursing Care Delivery Systems Pros and cons debated Must optimize nurse’s knowledge, skills Ensure that patients receive appropriate care Lower mortality rates in hospitals with good environments for nurses

Functional Nursing RNs, LPNs, and UAPs are assigned different tasks RNs assess patients Other staff give baths, make beds, take vital signs, and administer treatments

Figure 3-1 Functional nursing.

Functional Nursing Advantages Disadvantages Staff become efficient at performing assigned tasks Disadvantages Uneven continuity Lack of holistic understanding of patient Problems with follow-up

Team Nursing Team of nursing personnel provides total care to a group of patients by diagnosis or provider services. RN leads team May include other RNs, LPNs, and UAPs Leaders must be skilled in delegating, communicating, and problem solving All members of effective teams are good communicators

Team leader time spent in indirect pt care e.g.: Developing or updating nsg care plan Resolving problems encountered by team members. Conducting nsg conferences Communicating with physicians and other care providers

Figure 3-2 Team/modular nursing.

Team Nursing Advantages LPNs and UAPs perform tasks that do not require RN's expertise Care is more easily coordinated Saves steps and time

Team Nursing Disadvantages Time needed for communicating, supervising, and coordinating team members Affect of changes in team leaders, members, and assignments on continuity of care Total patient not considered by any one person

Team Nursing Disadvantages Role confusion and resentment Less control for nurses over assignments Possibility of unequal assignments

Figure 3-3 Total patient care.

Total Patient Care RN is responsible for all aspects of care for one or more patients

Total Patient Care Advantages Disadvantages Continuous, holistic, expert nursing care Total accountability Continuity of communication Disadvantages RNs perform tasks that could be done more cost-effectively by less skilled persons

Primary Nursing RN designs, implements, and is responsible for nursing care for duration of the patient's stay on the unit

Figure 3-4 Primary nursing.

Primary Nursing Advantages Knowledge-based practice model Decentralization of decisions, authority, and responsibility 24-hour accountability Improved continuity and coordination of care Increased nurse, patient, and physician satisfaction

Primary Nursing Disadvantages Excellent communication required Accountability of associate nurses Patient transfers disrupt continuity of care Compensation and legal responsibility for staff nurses Unwillingness of associates to take direction

Practice Partnerships RN and partner (UAP, LPN, or less experienced RN) work together on same schedule with same group of patients

Figure 3-5 Practice partnerships.

Practice Partnerships Advantages Improved continuity of care and accountability for care Disadvantages Decreased ratio of RNs to nonprofessional staff Potential for junior team members to assume too much responsibility

Case Management Is a model for identifying, coordinating, and monitoring the implementation of services needed to achieve desired patient care outcomes within specific period of time Case manager supervises the care provided by licensed and unlicensed nursing personnel Critical pathways provide direction for managing care of specific patients

Nsg case management requires Collaboration of all members of the health care team Identification of expected patient outcomes within specific time frame Use of principles of continuous quality improvement Promotion of professional practice

Figure 3-6 Case management.

Case Management Advantages Disadvantages All professionals equal team members Members take ownership of patient outcomes Disadvantages Requires qualified nurse case manager, team collaboration, and quality management system Established critical pathways needed

Critical Pathways Provide care strategies to achieve expected outcomes Used in case management system Include ways to identify variances easily and whether outcomes have been met

Critical Pathways Advantages Disadvantages Accommodate unique characters, conditions of patients Reduce costs Disadvantages May need revision

Differentiated Practice Structure of roles and functions differentiated by nurses' education, experience, and competence Roles, responsibilities, and tasks defined for professional nurses, LPNs, and UAPs

Differentiated Practice Maximizes nursing resources Defined scope of practice and level of responsibility

Patient-Centered Care Nurse coordinates a team of multifunctional, unit-based caregivers All patient care services are unit-based Focused on: Decentralization Promotion of efficiency and quality Cost control

Patient-Centered Care Advantages Promotes efficiency, quality, and cost control Disadvantages Requires considerable time for nurse manager Demands a strong leader to manage staff

Synergy Model of Care Patient characteristics and nurse competencies match Meets standards for Magnet certification

Pt ch:ch include: Resiliency, vulnerability, stability, complexity, resource availability participation in care, participation in decision making, predictability

The chch of pt should match with nurse competencies Clinical judgment Advocacy and moral agency Caring practice, collaboration, systems thinking, response to diversity, facilitation of learning, clinical inquiry

Clinical Microsystems Small unit of care that maintains itself Dynamic, interactive, self-aware, and interdependent Proven to improve teamwork, communication, and continuity of care

Evolution of Models for Delivering Care No system perfect or permanent Change caused by: Reimbursement changes Demands for quality Technologicial changes

Using the System Effectively Communication skills Ability to delegate Problem-solving skills