Question 1: The primary focus of my practice and my place of employment is diagnosis and treatment, but we also branch out

into the initial stages of rehabilitation and once the patient is able to participate shift the focus of care to illness prevention and maintenance of health. My place of employment is a not-for-profit hospital and this impacts employees several ways. Due to the fact that the hospital relies on insurance reimbursement, donations and charity we are tightly bound by the control of the insurance companies and what they are willing to pay and when they are not willing to pay. My practice itself does not change because of the hospital being a not-for-profit, but covered services may change. Quality and safety are HUGE issues and these areas are reflected in our mandatory education and well as bi-annual evaluations. With the list of NEVER events ever growing from the insurance reimbursement point of view there has been a renewed and continuing push to completely prevent pressure ulcers, patient falls, and catheter associated urinary tract infections and so on. Unfortunately the reality in providing healthcare is that you rely on and spend a lot of time dealing with insurance agencies as well as federal versions of healthcare coverage. Quality is something that should be provided at a baseline and should be expected from every patient entering any healthcare providing agency. However, now quality and satisfaction are being tied together to equal a reimbursement value from Medicare/Medicaid thus making customer satisfaction another top agenda in addition to quality and safety. Question 2: In my place of employment and on the critical care unit the health care team is multidisciplinary. Health care is delivered by medical staff, nursing staff, clinical pharmacists, dieticians, social workers, pastoral care, palliative care, nurse case managers, respiratory therapists, physical and occupational therapists, massage therapists, and speech therapists. Providing health care for the patient as a whole takes involvement from a team and participation from all areas of health care providers. Where I work most of the time all of the care team members work together seamlessly. Each provider has his or her own perspective and specialty care to offer, thus we all work together and complement each other providing well rounded and balanced care to the patient. In a critical care unit team work is not just desirable, it is necessary. People who do not work well or participate as a team member usually find themselves a new area to work in or learn and adapt to what it means to play as a team! I think that I regularly fulfill the role or care provider, educator, counselor, manager and collaborator daily at work. When I am working on the floor and have a patient assignment I am the direct care provider for the patients under my care. I work to educate the patient if they are able to understand and participate; I educate the family and field questions and concerns, and frequently readdress educational needs and learning and reassess a patients ability to learn. I am a counselor and listening/sounding board for patients and family members. I provide support

directly, or enlist the necessary help from social work, pastoral care, or palliative care as needed or required. I evaluate not only the patient in the bed, but the whole picture to make sure all of the needed specialties and resources are available and enlisted in their care. Daily I enlist and utilize research and best practice, but I do not regularly participate in research agendas or investigations. Collaboration is huge in my daily practice, with critically ill patient multiple specialty medical groups are involved in addition to our multidisciplinary team. I not only collaborate with all of my co-health care providers and specialists, I collaborate with my patient and his or her family to assure the best care and outcome possible. The nursing care delivery model most prominent in my place of employment is primary nursing missed with patient-centered care. On my unit each nurse is assigned between one and three patients based on acuity and is responsible and accountable for providing care to those patients. While every nurse starts work with a specific assignment, as patient acuity changes the nurse might also change but the patient remains in the same room. Our care is patient centered in that we offer a multidisciplinary care team and tailor patient care based on patient wishes. The hospital has several water features, works of art, painted/wallpaper walls, wood floors, food on demand with a menu designed for multiple different diet restrictions, music therapy, pet therapy, spiritual care, chapels, and massage therapy all designed with patient-centered care in mind. The advantages of primary nursing are immense with good relationships and trust developed between nurses and patients and families, full care of the patient within your assignment, and continuity of care which usually raises patient satisfaction. The disadvantage comes in when you have a particularly difficult/demanding patient and friction with patient or family members. On my floor we do primary nursing, but work within pods. We have pod mates and at the start of the day have a pod huddle to gain familiarity with all of the patients within our given pod so as to enable us to provide cross coverage for one another during breaks or when a pod nurse is traveling off of the floor. Patient-centered care promotes patient satisfaction and allows a patient to have some semblance of control over their healthcare and situation. Teamwork and collaboration are paramount in patient centered care and many specialties are utilized to provide whole person care. The biggest disadvantage to patient-centered care is the time that it takes to assure that the right nurse is placed with the right patient to deliver the right care. Overall I think that a union of primary nursing and patient-centered care is optimal for safe and quality health care delivery.