Additional Learning Exercises and Applications
DISPLAY 14.2 Traditional Patient Care Delivery Methods
Total patient care Functional nursing Team and modular nursing Primary nursing
Case management
When closely examined, many of the newer models of patient care delivery systems are merely recycled, modified, or retitled versions of older models. Indeed, it is sometimes difficult to find a delivery system true to its original version or one that does not have parts of others in its design. Although some of these care delivery systems were developed to organize care in hospitals, most can be adapted to other settings. The choice of an organization model involves staff skills, availability of resources, patient acuity, and the nature of the work to be performed.
Many of the newer models of patient care delivery systems are merely recycled, modified, or retitled versions of older models.
Total Patient Care Nursing or Case Method Nursing
Total patient care is the oldest mode of organizing patient care. With total patient care, nurses assume total responsibility during their time on duty for meeting all the needs of assigned patients. Total patient care nursing is sometimes referred to as the case method of assignment because patients may be assigned as cases, much like the way private duty nursing was historically carried out.
Indeed, at the turn of the 19th century, total patient care was the predominant nursing care delivery model.
Care was generally provided in the patient’s home, and the nurse was responsible for cooking, house cleaning, and other activities specific to the patient and family in addition to traditional nursing care. During the Great Depression of the 1930s, however, people could no longer afford home care and began using hospitals for care that had been performed by private duty nurses in the home. During that time, nurses and students were
the caregivers in hospitals and in public health agencies. As hospitals grew during the 1930s and 1940s, providing total care continued to be the primary means of organizing patient care.
This method of assignment is still widely used in hospitals and home health agencies. This organizational structure provides nurses with high autonomy and responsibility. Assigning patients is simple and direct and does not require the planning that other methods of patient care delivery require. The lines of responsibility and accountability are clear. The patient theoretically receives holistic and unfragmented care during the nurse’s time on duty.
Each nurse caring for the patient can, however, modify the care regimen. Therefore, if there are three shifts, the patient could receive three different approaches to care, often resulting in confusion for the patient. To maintain quality care, this method requires highly skilled personnel and thus may cost more than some other forms of patient care. This method’s opponents argue that some tasks performed by the primary caregiver could be accomplished by someone with less training and therefore at a lower cost. A structural diagram of total patient care is shown in Figure 14.1.
The greatest disadvantage of total patient care delivery occurs when the nurse is inadequately prepared or too inexperienced to provide total care to the patient. In the early days of nursing, only registered nurses (RNs) provided primary care; now some hospitals assign licensed vocational nurses (LVNs)/licensed practical nurses (LPNs) as well as unlicensed health-care workers to provide much of the nursing care. Because the coassigned RN may have a heavy patient load, little opportunity for supervision may exist and this could result in unsafe care.
LEARNING EXERCISE
14.1
How Many Patients Are Too Many? (Marquis & Huston, 2012)
A
ssume you are totally responsible for a patient’s care, including bathing, bed making, vital signs, all medications, managing intravenous (IV) lines, updating their patient care plan and carrying out all ordered treatments, dressing changes, patient teaching and discharge planning, etc. What number of patients do you feel you could manage while providing them good quality patient care? When you observe nurses in your clinical facility, what number of patients do they care for? Write a one- to two-page essay detailing your response.Functional Method
The functional method of delivering nursing care evolved primarily as a result of World War II and the rapid
construction of hospitals as a result of the Hill Burton Act. Because nurses were in great demand overseas and at home, a nursing shortage developed and ancillary personnel were needed to assist in patient care. These relatively unskilled workers were trained to do simple tasks and gained proficiency by repetition. Personnel were assigned to complete certain tasks rather than care for specific patients. Examples of functional nursing tasks were checking blood pressures, administering medication, changing linens, and bathing patients. RNs became managers of care rather than direct care providers, and “care through others” became the phrase used to refer to this method of nursing care. Functional nursing structure is shown in Figure 14.2.
The functional form of organizing patient care was thought to be temporary, as it was assumed that when the war ended, hospitals would not need ancillary workers. However, the baby boom and resulting population growth immediately following World War II left the country short of nurses. Thus, employment of personnel with various levels of skill and education proliferated as new categories of health-care workers were created.
Currently, most health-care organizations continue to employ health-care workers of many educational backgrounds and skill levels.
Most administrators consider functional nursing to be an economical and efficient means of providing care.
This is true if quality care and holistic care are not regarded as essential. A major advantage of functional nursing is its efficiency; tasks are completed quickly, with little confusion regarding responsibilities.
Functional nursing does allow care to be provided with a minimal number of RNs, and in many areas, such as the operating room, the functional structure works well and is still very much in evidence. Long-term care facilities also frequently use a functional approach to nursing care.
During the past decade, however, the use of unlicensed assistive personnel (UAP), also known as nursing assistive personnel, in health-care organizations has increased. Many nurse administrators believe that assigning low-skill tasks to UAP frees the professional nurse to perform more highly skilled duties and is therefore more economical; however, others argue that the time needed to supervise the UAP negates any time savings that may have occurred. Most modern administrators would undoubtedly deny that they are using functional nursing, yet the trend of assigning tasks to workers, rather than assigning workers to the professional nurse, resembles, at least in part, functional nursing.
Functional nursing may lead to fragmented care and the possibility of overlooking patient priority needs. In addition, because some workers feel unchallenged and understimulated in their roles, functional nursing may result in low job satisfaction. Functional nursing may also not be cost-effective due to the need for many coordinators. Employees often focus only on their own efforts, with less interest in overall results.
Team Nursing
Despite a continued shortage of professional nursing staff in the 1950s, many believed that a patient care system had to be developed that reduced the fragmented care that accompanied functional nursing. Team
nursing was the result. In team nursing, ancillary personnel collaborate in providing care to a group of patients under the direction of a professional nurse. As the team leader, the nurse is responsible for knowing the condition and needs of all the patients assigned to the team and for planning individual care. The team leader’s duties vary depending on the patient’s needs and the workload. These duties may include assisting team members, giving direct personal care to patients, teaching, and coordinating patient activities. Team nursing structure is illustrated in Figure 14.3.
LEARNING EXERCISE
14.2
Transitioning to Total Patient Care
M
ost nursing students begin their clinical training by doing some form of functional nursing care and then advancing to total patient care for a small number of patients. Reflect back to your earliest clinical experiences as a student nurse. Which tasks were easiest for you to learn? How did you gain mastery of those tasks? Was task mastery a time-consuming process for you? Was it difficult to make the transition to total patient care? If so, why? What skills were most difficult for you to learn in providing total patient care? Do you anticipate having to learn additional skills to feel comfortable in the role of total care provider as an RN? What higher level skills do you think will be the hardest to learn and be confident with?Through extensive team communication, comprehensive care can be provided for patients despite a relatively high proportion of ancillary staff. This communication occurs informally between the team leader and the individual team members and formally through regular team planning conferences. A team should consist of not more than five people or it will revert to more functional lines of organization.
Team nursing is also usually associated with democratic leadership. Group members are given as much autonomy as possible when performing assigned tasks, although the team shares responsibility and accountability collectively. The need for excellent communication and coordination skills makes implementing team nursing difficult and requires great self-discipline on the part of team members.
Team nursing also allows members to contribute their own special expertise or skills. Team leaders, then, should use their knowledge about each member’s abilities when making patient assignments. Recognizing the
individual worth of all employees and giving team members autonomy results in high job satisfaction.
Disadvantages to team nursing are associated primarily with improper implementation rather than with the philosophy itself. Frequently, insufficient time is allowed for team care planning and communication. This can lead to blurred lines of responsibility, errors, and fragmented patient care. For team nursing to be effective then, the team leader must be an excellent practitioner and have good communication, organizational,
management, and leadership skills.
The Multidisciplinary Team Leader Role
One of the recommendations of the 2010 Institute of Medicine Report, The Future of Nursing, was to expand the opportunities for nurses to lead and diffuse collaborative improvement efforts with physicians and other members of the health-care team to improve practice environments (Robert Wood Johnson Foundation [RWJ], 2011). Some health-care organizations currently incorporate pharmacists, social workers, occupational therapists, speech therapists, and other health-care workers as part of the multidisciplinary team to assure that comprehensive and holistic health care can be provided to each patient, although the responsibility for team leadership still often falls to the RN. Implementation problems are common, however, in multidisciplinary teams, as having experts on teams is different than having expert teams; each discipline may believe that their perspective is most important and undervalue the contributions of other team members.
In addition, like traditional team nursing, multidisciplinary teams require an efficient means of
communication about patient goals, progress, and problems. It is not often easy to find opportunities for the whole team to meet because of work shift patterns or other work commitments. In addition, sometimes, there are challenges in determining who the members of the team should be and who should be the leader of the team.
Modular Nursing
Team nursing, as originally designed, has undergone much modification in the last 30 years. Most team nursing was never practiced in its purest form but was instead a combination of team and functional structure.
More recent attempts to refine and improve team nursing have resulted in many models including modular nursing.
Most team nursing was never practiced in its purest form but was instead a combination of team and functional structure.
Modular nursing uses a mini-team (two or three members with at least one member being an RN), with members of the modular nursing team sometimes being called care pairs. In modular nursing, patient care units are typically divided into modules or districts, and assignments are based on the geographical location of patients.
Keeping the team small in modular nursing and attempting to assign personnel to the same team as often as possible should allow the professional nurse more time for planning and coordinating team members. In addition, a small team requires less communication, allowing members better use of their time for direct patient care activities.
LEARNING EXERCISE
14.3
Reorganizing to Accommodate a Change in Staffing Mix
Y
ou are the head nurse of an oncology unit. At present, the patient care delivery method on the unit is total patient care. You have a staff composed of 60% RNs, 35% licensed practical nurses/licensed vocational nurses (LPNs/LVNs), and 5% clerical staff. Your bed capacity is 28, but your average daily census is 24. An example of day-shift staffing follows:One charge nurse who notes orders, talks with physicians, organizes care, makes assignments, and acts as a resource person and problem solver
Three RNs who provide total patient care, including administering all treatments and medications to their assigned patients, giving IV medications to the LVN/LPNs’ assigned patients, and acting as a clinical resource person for the LVN/LPNs
Two LVN/LPNs assigned to provide total patient care except for administering IV medications Your supervisor has just told all head nurses that because the hospital is experiencing financial difficulties, it has decided to increase the number of nursing assistants in the staffing mix. The nurses on your unit will have to assume more supervisory responsibilities and focus less on direct care. Your supervisor has asked you to reorganize the patient care management on your unit to best use the following day-shift staffing: three RNs, which will include the present charge nurse position; two LVN/LPNs; and two nursing assistants. You may delete the past charge nurse position and divide charge responsibility among all three nurses or divide up the work any way you choose.
A S S I G N M E N T:
Draw a new patient care organization diagram. Who would be most affected by the reorganization?
Evaluate your rationale for both the selection of your choice and the rejection of others. Explain how you would go about implementing this planned change.
Primary Nursing
Primary Nursing in the Inpatient Setting
Primary nursing, also known as relationship-based nursing, was developed in the late 1960s, uses some of the concepts of total patient care and brings the RN back to the bedside to provide clinical care. According to Manthey (2009), “the foundational principles of primary nursing were revolutionary: For the first time in hospital nursing, explicit responsibility and authority for specific patients were clearly allocated to a specific registered nurse (whose license by law permits independent decision making about nursing care). At no time in the history of hospital nursing, had that degree of professional control over nursing practice been
organizationally sanctioned at the staff nurse level” (p. 36). This required a major redesign of unit
organizations, administrative structures, and managerial philosophy as well as a challenging transformation of roles and relationships at the point of patient care (Manthey, 2009).
In inpatient primary nursing, the primary nurse assumes 24-hour responsibility for planning the care of one or more patients from admission or the start of treatment to discharge or the treatment’s end. During work hours, the primary nurse provides total direct care for that patient. When the primary nurse is not on duty, associate nurses, who follow the care plan established by the primary nurse, provide care. Many experts have suggested that the role of the primary nurse should be limited to RNs; however, Manthey (2009) argues that primary nursing can succeed with a diverse skill mix just as team nursing or any other model can succeed with an all-RN staff. Primary nursing structure is shown in Figure 14.4.
Primary nursing can succeed with a diverse skill mix just as team nursing or any other model can succeed with an all-RN staff.
Although originally designed for use in hospitals, primary nursing can lend itself well to home health nursing, hospice nursing, and other health-care delivery enterprises as well. An integral responsibility of the primary nurse is to establish clear communication among the patient, the physician, the associate nurses, and other team members. Although the primary nurse establishes the care plan, feedback is sought from others in coordinating the patient’s care. The combination of clear interdisciplinary group communication and consistent, direct patient care by relatively few nursing staff allows for holistic, high-quality patient care.
Although job satisfaction is high in primary nursing, this method is difficult to implement because of the degree of responsibility and autonomy required of the primary nurse. However, for these same reasons, once nurses develop skill in primary nursing care delivery, they often feel challenged and rewarded.
Disadvantages to this method, as in team nursing, lie primarily in improper implementation. An inadequately prepared or incompetent primary nurse may be incapable of coordinating a multidisciplinary team or identifying complex patient needs and condition changes. Many nurses may be uncomfortable in this role or initially lack the experience and skills necessary for the role. In addition, although an all-RN nursing staff has not been proved to be more costly than other modes of nursing, it sometimes has been difficult to recruit and retain enough RNs to be primary nurses, especially in times of nursing shortages. Other challenges in implementing primary nursing include “shorter lengths of stay, increasing numbers of part-time positions, and variable shift lengths, combined with the ongoing pragmatic need to provide holistic, coordinated care to human beings” (Manthey, 2009, p. 37). These logistical issues can best be managed by unit-based decisions arrived at through the consensus of a unified and cohesive staff (Manthey, 2009).
Registered Nurse Primary Care Coordinators in Patient-Centered Medical Homes
One model enacted as part of the Patient Protection and Affordable Care Act (PPACA) was the establishment of the Patient-Centered Medical Home (PCMH). The PCMH delivers cost-effective, primary care, utilizing care coordination, ensuring high value and improving health outcomes. RNs are increasingly serving as the front line primary care leaders in PCMHs alongside physicians and advanced practice nurses. In this role, RNs engage patients and families in care coordination, enhance care transition, manage complex chronic patient care plans, and promote preventive care services to empower patient self-care (Baker, 2015). Unfortunately, neither urban nor rural settings have developed a comprehensive definition of what RN primary care coordination is, nor is it being implemented in a uniform manner.
To address this problem, Baker (2015) conducted a literature review and conducted interviews with rural primary care providers. The domains of practice she identified for the RN primary care coordinator and the job description she created for that role are detailed in Examining the Evidence 14.1.
EXAMINING THE EVIDENCE 14.1
Source: Baker, K. (2015). An emerging role for RN’s: The RN primary care coordinator. Oklahoma Nurse, 60(3), 13–14.
Using a diffusion of innovation framework, Baker completed a literature review and interviews with rural primary care providers. Her study findings yielded seven domains for care management for the RN primary care coordinator. She then wrote a job description for RN primary care coordinators that
encompassed these seven domains. The seven domains required for primary care coordination included the following:
1. Population health management: A change from a focus on a single provider caring for the health and well-being of an individual patient to a focus on a health-care team managing the health of a panel of patients 2. Comprehensive assessment and care planning: A thorough knowledge of
chronic disease management and evidence-based guidelines and
protocols, especially for chronic heart failure (CHF), chronic obstructive pulmonary disorder (COPD), diabetes, and depression
3. Interpersonal communication: Includes the ability to use different communication styles, including active listening, to counsel, interview, resolve conflict, build relationships, and develop effective
interdisciplinary teams
4. Education/coaching: A working knowledge of adult education principles and learning techniques, readiness to change, and identification of necessary person-centered components for a self-management plan 5. Health insurance and benefits: Current knowledge of health insurance,
managed care, and other payer sources and benefits.
6. Community resources: A thorough familiarity of public and private community-based providers, services, and support available in the local geographical area
7. Research and evaluation: A basic understanding of research and evaluation techniques to assist in quality improvement of care and interpretation of program outcomes.
Interprofessional Primary Health-Care Teams
Like team nursing, primary care has expanded to interdisciplinary teams. Sibbald, Wathen, Kothari, and Day (2013) note primary health-care teams (PHCTs) are interprofessional teams that include, but are not limited to, physicians, nurse practitioners, nurses, physical therapists, occupational therapists, and social workers who work collaboratively to deliver coordinated patient care. “Team-based models of PHCT delivery have been created to achieve (or work toward) several benefits to the health system, health care providers, and patients, including better coordination of care, increased focus on collaborative problem solving and decision making, and a commitment to patient-centered care” (Sibbald et al., 2013, p. 129). The desired outcomes for PHCTs are reduced mortality and improved quality of life for patients, a reduction in health-care costs, and a more rewarding professional experience for the health-care worker.
The challenges to implementing primary health care on the PHCT mirror many of the challenges seen in more traditional primary care, including hurdles in their formation, overcoming the traditional physician- dominated hierarchy in determining who should lead the team, role confusion, and determination of structure and function of the team. For example, Hart’s (2015) research found that perceptions of status influenced participation on an interprofessional team and that underlying tensions existed, despite an overarching