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 Patient classification systems/acuity level Categorize patients according to care needs

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

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 areas—intensive care unit (ICU) and postanesthetic care unit (PACU)

Total Patient Care—cont’d Advantages High degree of autonomy Lines of responsibility and accountability are clear Patient receives holistic, unfragmented care Disadvantages Each RN may have a different approach to care Not cost-effective Lack of RN availability

Total Patient Care (Case Method) Delivery The registered nurse plans, organizes, and performs all care Registered Nurse 8-hour shift 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 area—operating room

Functional Nursing—cont’d Advantages Care is provided economically and efficiently Minimum number of RNs required Tasks are completed quickly Disadvantages Care may be fragmented Patient may be confused with many care providers Caregivers feel unchallenged

Functional Nursing Care Delivery Model Nurse Manager LPN/ PO Meds Treatments RN Assessments Care Plans Nurse Aide Vital signs 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 areas—most inpatient and outpatient areas

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

Team Nursing Model Nurse Manager RN Team Leader RN LPNs Nursing Assistants 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 Nursing—cont’d Advantages Continuity of care is improved RN more involved in planning and coordinating care Geographic closeness and efficient communication Disadvantages Increased costs to stock each module Long corridors not conducive to modular nursing

Modular Nursing Model Nurse Manager Geographic Patient Unit Patient Care Team: RNs LPNs Nurse Aides Meds Supplies Linens LPNs/ Nurse Manager 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 areas—hospice, home health, and long-term care settings

Primary Nursing—cont’d Advantages High-quality, holistic patient care Establish rapport with patient RN feels challenged and rewarded Disadvantages 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

Primary Nursing Model Patient Primary Nurse 24-hour responsibility for planning, directing & evaluating patient care Patient Associate Nurses Provide care when primary nurse is off duty Physician and other members of the health care team 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)—cont’d Advantages More cost-effective than primary nursing RN can encourage training and growth of partner Disadvantages RN may have difficulty delegating to partner Consistent partnerships difficult to maintain due to varied schedules

Patient-Centered Care (Patient-Focused Care) Cross-functional teams of professionals and assistive personnel work together as a unit-based 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)—cont’d 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)—cont’d 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

Patient Patient-Centered Care Model Nurse Manager Patient Care Respiratory Services Patient Transportation Housekeeping ECG Admission/Discharge Phlebotomy Physical/Occupational/Speech Therapy Dietary Services Financial Counseling Supply Management 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 Management—cont’d 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 patient’s 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)

Nursing Case Management Model NURSE CASE MANAGER Assesses, plans, implements, coordinates, monitors, and evaluates patient care options and services to meet health needs Onset of Illness Resolution of Collaborates with Nursing, Physicians, Physical/Speech/ Occupational Therapists, Dietary, and Ancillary Services Collaborates With Patient and Family 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 Self-care activities Nutrition Patient and family education Discharge planning Triggers Consults Laboratory and diagnostic tests Treatments Medications Safety

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 Organizational structure and resources Management, staffing, supplies, and physical layout Patient needs Acute, long-term, and chronic

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?