So in this lesson, we are going to take a look at some different models of delivering health care to our patients.
So, what are nursing care delivery models?
Well, they’re different methods that hospitals and nurses use to set up and deliver care. They can include charge nurses, team leaders, other nurses, and care techs or assistants.
The four we are going to look at today are Functional Nursing, Team Nursing, Total Patient Care and Primary Nursing. So let’s take a look at each of them.
Functional nursing is really unique. It involves multiple nurses, who have very specific tasks. For instance, let’s say you have Jon, Nichole and Tony, all nurses on the floor. Well, Jon is responsible for giving meds, Nichole is responsible for, let’s say, IVs, and Tony is responsible for assessments. So during the shift, Jon would pass out all of the medications, Nichole would manage the IVs and Tony would assess all of the patients.
There are definitely pros and cons to this setup. The biggest pro is that it is extremely efficient. Because every nurse has a specific job, they’re not doing all aspects of care, so every individual task gets done more efficiently. But, that actually leads to one of the major cons of functional nursing. Holistic care. This is a fractured model, and it doesn’t paint the big picture as to how well a patient is or isn’t doing. It also relies on multiple nurses, so if there are staffing issues, then there could be gaps in care. This is why this model isn’t prevalently used.
However, here’s a great situation where it DOES work well. That’s a code team. Every nurse has their own individual responsibility. This means that care is clear and concise, and efficient. You have a med nurse, a recorder, someone doing compressions, someone doing lines, someone running to get supplies…this is where it’s extremely beneficial. But on the whole, for patient-centered care, this model can really fall short in areas of care.
Team nursing is a very popular delivery model, and it’s often seen in high-acuity areas like ICUs or Emergency Departments.
Basically, it works like this. You have a team leader, or a charge nurse, who makes assignments, coordinates care with other doctors and other team members and who speaks to all of the nurses on the unit. Under them, you have the multiple RNs who are caring for the patients on the unit. They’re responsible for directly giving care to the patients. They can delegate certain aspects of care, which is where the CNAs or PCTs come in. CNA stands for certified nurse assistant and PCT is a patient care tech. The techs and assistants can provide care like bathing, turning, assisting to the bathroom or other things that don’t require nursing assessment.
This is a really common type of nursing care model, but it does have some drawbacks. A common complaint is that the charge nurse or team leader doesn’t have direct interaction with the patient, or only with those who are acutely ill (like new admissions in an ICU). The other is that the team nursing model can create gaps in care, mainly because nurses may be pulled in different directions, depending on how sick other patients are on the unit. Other than that, the model allows nurses to collaborate to deliver high-quality care.
Total patient care is the model that we most commonly see. It’s basically shift based, so the nurse shows up for their shift, say, 7 a to 7 p and provides care for a patient or patients for the duration of that shift. Nurses are also responsible for all aspects of care (which also takes into account the care that you delegate). Also, the nurse coordinates care and care plans with the medical team or whatever providers are assigned for that patient.
Now, you can also have a combination of models. For example, in the ICU, it’s not uncommon to see the nurses delivering Total Patient Care, but they also function in a team nursing model. And in the event of a code, those nurses would then break down into a functional model, and then go back to their care when the code ended.
Now the last model isn’t too common but is still out there. And it’s the primary nursing model.
The way this model works is that you have a nurse assigned to care for a patient. They care for the patient for the duration of their stay. So let’s say you’re working in a skilled nursing facility, and they use a primary nursing model. You’d be required to create care plans, coordinate care and talk to the medical team for that patient during the entire duration of their stay, until they were either discharged or transferred to another facility. The other important thing to note about this model is that the nurse manages the case even when they’re not there – meaning that the care plans are followed by the primary nurse, unless something happens which requires some pretty course altering intervention (for example, the patient develops an acute respiratory infection and decompensates). This model helps to foster the nurse-patient relationship, especially when a patient has to be in one place for a long time. Sometimes, it’s more than one client, so think home health or hospice. Not all care is required by the nurse, but all of the care given to the patient or patients is the RESPONSIBILITY of the nurse, so think about that when you’re delegating tasks. Delegation is covered in pretty good detail in another lesson, so check that one out.
Nursing care delivery models focus heavily on how we give care to our patients. We focus on teamwork and collaboration and putting the patients in our main area of focus. We work to make their care as high of quality as we can, and try to use models or variations of models to do that. Also, we want to focus on professionalism, and how we deliver care in a meaningful and professional manner.
So to recap, in functional nursing, every nurse has their own task. Overall, it’s efficient, but it has some flaws. Team nursing is just that – team focused, where nurses can collaborate with care, and there’s a nurse who serves as their leader. In total patient care, the nurse is responsible for all of the care throughout a shift, including what’s delegated. Primary nursing is set up to foster the nurse-patient relationship, so a nurse is assigned to that patient for the duration of their care. And lastly, know your model that you’re working in and know what your responsibilities are. These models can change frequently. A code in an ICU can shift from total patient and team to functional quickly and then resolve back to a team model in no time.
Make sure you check out all the resources attached to this lesson. Now, go out and be your best selves today. And, as always, happy nursing!!
Chapter 13 Care Delivery Strategies
ANS: D
Differentiated nursing practice models are models of clinical nursing practice that are defined or differentiated by level of education, expected clinical skills or competencies, job descriptions, pay scales, and participation in decision making.
Complex care of acutely ill patients is required on a surgical unit, which utilizes differentiated nursing practice as its model of care delivery. The concept of differentiated nursing practice is based on:a. Licensure status.
b. Experience in the agency
ANS: A
Because the basic education of baccalaureate-prepared RNs emphasizes critical-thinking, clinical reasoning, and leadership concepts, they are likely candidates for such roles. Benner (2001), however, identified five stages of clinical competence fo
The relief charge nurse has assigned a newly licensed baccalaureate-prepared nurse to be one of the team leaders for the 3-11 shift. In making this decision, the charge nurse has overlooked this nurse's:a. Clinical expertise.b. Leadership ability.
c. Co
ANS: B
The functional model of nursing is a method of providing patient care by which each licensed and unlicensed staff member performs specific tasks for a large group of patients.
When interviewing an applicant for a position, the nurse manager describes the unit's care delivery system as one in which each nursing assistant is cross-trained to perform specific tasks, and the RNs do all treatment, medication administration, and disc
ANS: C
A critical pathway outlines outcomes, clinical standards, and interventions for a patient in each phase of treatment. The goal of critical pathways is effective coordination of care across various staff and levels of care.
You are the nurse manager of a nursing service organization that provides around-the-clock care to clients in their homes. To achieve maximum reimbursement for a client who is recovering from a hip replacement, the nursing staff most likely will follow th
ANS: D
The goals and outcomes established in a critical pathway are designed to support the aims of case management, which are shortened hospital stays and prevention of hospital readmissions.
The nurse case manager is working with a client admitted for end-stage renal disease. The case manager's major goal during this hospitalization is to:a. Implement the care pathway on admission.
b. Provide direct nursing care throughout the hospitalizatio
ANS: B
Team nursing, functional nursing, and case management are all considered efficient, cost-effective methods of care delivery because they enable utilization of various types of healthcare providers (rather than baccalaureate nurses in direct care, w
The nurse manager at a cardiac rehabilitation unit was asked to select a care delivery model. Which of the following methods would be the most cost-effective?a. Functional methodb. Case management methodc. Primary care method
d. Team method
ANS: D
In a functional nursing model, where other team members are focused on performing specific tasks, the nurse manager assumes primary responsibility for patient outcomes.
In an acute care unit, the nurse manager utilizes the functional nursing method as the care delivery model. The nurse manager's main responsibility is the needs of the:a. Department.b. Unit.c. Staff.
d. Patient.
ANS: A
Because of the breadth of nursing knowledge required, baccalaureate education is preferred for primary nurses.
A patient is admitted to a medical unit with pulmonary edema. His primary nurse admits him and then provides a written plan of care. What type of educational preparation best fits the role of primary nurse?a. Baccalaureateb. Associatec. Diploma
d. LPN/
ANS: C
The partnership care delivery model is a variation of primary nursing in which an RN works with a consistent assistant, who performs basic nursing functions consistent with state delegation rules.
In a small rural nursing home, a director of nursing decides, because of a shortage of nurses, to implement a partnership model to help with basic tasks that comply with state rules regarding delegation. What type of design constitutes a partnership care
ANS: C
This model is especially useful in the care of complex patients who need active symptom management provided by an RN, such as the care of the patient in a hospice setting or an intensive care unit. This method would be justifiable delivery in the p
The case method of care delivery could be best justified in which of the following scenarios?a. Stable patient population with long-term care and family needs
b. Acute care surgical unit with predictable postsurgical outcomes and many technical procedure
ANS: A
The case method may involve total patient care provided by a registered nurse, which, in today's costly healthcare economy, is very expensive. In times of nursing shortages, there may not be enough resources or nurses to use this model.
During times of nursing shortages and increased nursing costs in health care, which of the following nursing care delivery models might come under greatest scrutiny?a. Case methodb. Team nursingc. Functional nursing
d. Nurse case management
ANS: C
Functional team nursing involves licensed and unlicensed personnel who perform specific tasks for a large number of patients. A disadvantage of functional team nursing is the fragmentation of care. The physical and technical aspects of care may be
A patient complains to you that she has no idea who "her nurse" is on any given day. "I ask one nurse for my pills and she says, 'That's not my job.' I ask the pill nurse about my lab tests and she says that I should ask another nurse." The nursing care d
ANS: D
An advantage of functional nursing is that both unskilled assistive personnel and skilled staff are involved in performance of specific tasks, and the repeated performance of tasks enables staff to become very efficient in specific functions. Disad
A patient complains to you that she has no idea who "her nurse" is on any given day. "I ask one nurse for my pills and she says, 'That's not my job.' I ask the pill nurse about my lab tests and she says that I should ask another nurse." This nursing care
ANS: A
Although repetition of tasks increases confidence and competence, it can also lead to boredom. Rotation of tasks can assist specifically in this model to reduce the boredom that is a potential disadvantage of this model.
For a nurse manager in the functional nursing model, an approach that will assist in maintaining staff satisfaction in this specific model is:a. Rotation of task assignments.b. Frequent opportunities for in-service education.
c. Orientation to job respo
ANS: C
A particular challenge in team nursing is that staff mixes and staff may change daily because of individual schedules and shortages.
To effectively delegate in a team nursing environment, the RN team leader must be familiar with the legal and organizational roles of each group of personnel and must:a. Be able to effectively communicate with patients.
b. Build relationships with physic
ANS: C
Significant overlap can be seen between primary nursing and total patient care in terms of breadth of assessment and knowledge required to provide holistic care. A primary difference is that nurses in the total care model assume accountability whil
A nurse manager questions the true difference between primary nursing and total patient care. After careful consideration of both models, the nurse manager concludes that primary nursing differs significantly from total patient care in:
a. Breadth of nurs
ANS: A
The primary nursing model assumes that the primary nurse is accountable for patient care, even while off duty. The primary nurse is responsible for establishing the patient plan of care and therefore for altering it with the input of an associate.
A conflict develops between an associate nurse and a primary nurse over the assessment of a patient with pulmonary edema. Based on her assessment of the patient, the associate nurse insists that it is her role to change the care plan because she is the on
ANS: D
Although some studies suggest there is little difference between functional nursing and primary nursing, primary nursing tends to be more satisfying for RNs, who enjoy a high level of accountability and autonomy in decision making. Patient satisfac
When comparing functional nursing and primary nursing, a nurse manager, after evaluating particular models of nursing care for potential adoption, determines that patient and nurse satisfaction in primary nursing are:
a. Similar to those in functional nur
ANS: B
The nurse manager who is considering movement to primary nursing needs to consider how the role of the manager changes, as well as the roles of the staff. The role of decision making at the patient care level is relinquished to the primary nurse, a
In transitioning to a primary nursing model, it is important for a nurse manager who enjoys a high level of control over patient care to understand that his or her decision making at the patient care level:a. Is increased.b. Is decreased.
c. Is relinqui
ANS: B
This particular model includes a focus on patient care that includes multidisciplinary teams and assistants at the bedside. Services, including laboratories and pharmacies, are decentralized to bring them closer to where care is delivered.
You are considering putting forward a proposal to move the model of care from team nursing to a primary nursing hybrid: patient-focused care model. In considering this proposal, you recognize that significant costs specific to operationalizing this model
ANS: D
Case managers can come from a variety of disciplines but should have advanced preparation with the particular at-risk population being served, be comfortable in an advocate role, and be outcome and patient focused.
When hiring a case manager for a rehabilitation setting, you would most likely consider a:a. Registered nurse with a master's degree.b. Physiotherapist with a background in stroke rehabilitation.c. Social worker with a background in counseling.
d. Heal
ANS: A
Case managed care is not revenue generating but rather revenue protecting in that better coordination of care enables efficient achievement of patient outcomes, can result in shorter length of stay, and can prevent readmission.
Case managed care may enhance profit in a for-profit health organization by:a. Minimizing costs in high resource consumption areas.b. Combining licensed and non-licensed care providers in delivering patient care.
c. Increasing reimbursement from third-p
ANS: B
Nurses who have less than 2 or 3 years' experience in primary nursing and/or less than 2 or 3 years of nursing experience will likely require more assistance than other nurses, which will put a greater demand on the unit during a time of transition
In hiring nurses during the transition from team nursing to a primary nursing model, Benner's work would suggest that you give priority to nurses who are at least at which level of competency?a. Advanced beginnerb. Competentc. Proficient
d. Novice
ANS: C
Magnet� hospitals exemplify hospitals whose focus processes attract and retain nurses who value and promote quality care and excellence in nursing environments.
In considering whether or not to accept a job offer as a nurse manager at a Magnet� hospital, you look at an environment that you might encounter as a head nurse at the hospital. You determine that you could expect to:
a. Find it difficult to recruit new
ANS: A, B, E
Transforming care at the bedside (TCAB) relies on active involvement of staff in the generation of innovative ideas to improve patient care. Staff are actively engaged in selecting innovation, planning, and evaluation of the innovations. Crit
Your organization has made a decision to implement TCAB in your hospital. As a manager, what strategies would you use to implement TCAB? (Select all that apply.)a. Encourage recognition among staff of their knowledge of the patient-care environment.
b. W
Case method(total patient care)
One nurse provides total care for one patient during the entire work period
Patient received consistent care, builds a trusting relationships works towards goals
Expensive, not enough resources, not enough nurses
Registered nurse role of case method
Provide holistic care, physical, emotional, and technical aspects of care
Providing patient care by which each licensed and unlicensed staff member perform specific tasks for a large group of patients
Functional nursing positives
Each person becomes efficient at specific task, and much work can be done in a short time. Unskilled workers can be trained to perform one or two specific task very well. The organization benefit financially from this model because care can be delivered t
Functional Nursing negatives
Fragmentation of care, physical and technical aspects of care may be met, but the psychological and spiritual needs may be overlooked. Patients become confused with so many different care providers per shift Staff members might become busy and forget to c
Functional nursing role of manager
Must be sensitive to the quality of patient care delivered and institutions budgetary constraints. Patient outcomes becomes the nurse managers responsibility
Functional nursing role of registered nurse
The staff RN become skilled at the task that are usually assigned by the charge nurse. Clearly defined policies and procedures are used to complete the physical aspects of care in an efficient and economical manner
A modification of functional nursing, was devised to improve patient satisfaction. care through others became the Hallmark
Advantages of team nursing
Improved patient satisfaction, organizational decision-making occurring at lower levels, and cost-effectiveness for the agency
Disadvantages of team nursing
Team leader has poor leadership skills causing a potential for fragmentation of care
Management skills, provide support, plans care, follow up with members to evaluate the quality of care
Registered nurse team nursing
Uses the strength of each caregiver example if you're good at an IV you do the IV every time
Method for organizing patient care delivery in which one registered nurse functions autonomously as the patient's primary nurse throughout the hospital stay
Advantages for primary nursing
Increase communication, increase patient rapport, autonomy,motivation, holistic care
Disadvantages of primary nursing
Costly for the agency, registered nurse may not want 24 hour responsibility, registered nurse maybe inexperience and lack autonomy
Advantages of nursing case management
Improve care outcome, decreased the length of stay in the hospital, service efficient
A tool that case managers use Trixie patient outcomes that use patient focused documents to describe the clinical standards necessary interventions and expected outcomes for the patient at each stage throughout the treatment process or hospital stay
Disadvantages case management nursing
Financial barriers, lack of administrative support, human resource inequalities, turf battles, and the lack of information support systems have been identified as obstacles in the implementation
The focus of this model of care is the concept of wellness, living well with a chronic disease. Determining the barriers to self-care is an essential element of successful disease management programs
Differentiated nursing practice
Defined by level of education, expected clinical skills or competencies, job descriptions, payscales, and participation and decision-making
Identifies patient characteristics as drivers of the necessary competencies for nurses
Eight patient characteristics of the energy model
Resiliency, vulnerability, stability, complexity, resource availability, participation in care, participation in decision making and predictability
The eight nurse competencies of synergy model
Clinical judgment, advocacy, caring practices, facilitation of learning, collaboration, systems thinking, response to diversity, and clinical requirement
Magnet recognition program
Designed for hospitals to achieve recognition of excellent nursing care through a self nominating, self appraisal process to achieve
Transforming care of the bedside
Implemented to redesign the work environment of nurses. Reliability, teamwork, patient centered care, value added care processes. Brainstorm innovations, plan/do/study
A rural, critical access hospital has used a total patient care model to deliver nursing care to patients because of the hospital's commitment to individualized care to patients in the community. Environmental factors such as a nursing shortage in the are
Patient-centered care
The patient-centered care model of care maintains the commitment to individualized care; however, it uses less expensive unlicensed assistive personnel to extend the practice of the registered nurse.
A hospital in a large metropolitan area hopes to obtain magnet status. The following are characteristics of the nursing service in this hospital. Select the areas that must be addressed in order to become a magnet hospital. (Select all that apply.)
The hospital has a nurse vacancy rate of 20%. CorrectThe chief nursing officer holds a MSN, with a specialty in nursing administration. NO50% of the nurse managers hold a BSN. Correct
Transforming Care at the Bedside has been implemented in all units. N
The most important role of the nurse case manager is to:
Serve as a communication link between all providers of care.
The primary role of the case manager, according to the Case Management Society of America, is to increase the involvement of individual and caregivers in the decision-making process.
A patient's family asks the nurse why a clinical pathway is being used to determine her care. The best answer is "Clinical pathways:
help everyone caring for you to provide effective care based on research findings.
Clinical pathways are designed to integrate research and best practices into the care.