STAFFING

AND NURSING
CARE DELIVERY MODELS

Nursing care delivery models

Nursing care delivery models,
also called care delivery systems
or patient care delivery models,
detail the way task assignments,
responsibility, and authority are
structured to accomplish patient
care.

Nursing care delivery

models
The nursing care delivery model
describes
1. which health care worker is going to
perform what tasks,
2. who is responsible, and
3. who has the authority to make
decisions.

Nursing care delivery

models
The basic premise of nursing
care delivery models is that the
number and type of caregivers
are closely matched to patient
care needs to provide quality
care in the most cost-effective
manner possible.

Nursing care delivery

models
The four classic nursing care
delivery models used during the
past five decades are
(1) total patient care,
(2) functional nursing,
(3) team nursing, and
(4) primary nursing.

Total Patient Care

The oldest method of organizing patient
care is total patient care, sometimes
referred to as case nursing. In total patient
care nurses are responsible for planning,
organizing, and performing all care,
including personal hygiene, medications,
treatments, emotional support, and
education required for their assigned
group of patients during the assigned shift.

Total Patient Care

Registered
Registered
Registered
nurse 8-hour
nurse8-hour
nurse8-hour
shift
shift
shift

Patient care

The registered nurse

plans, organizes,

and performs all care.

The total patient care (case method) delivery model.

Functional Nursing
In the functional nursing method of patient
care delivery, staff members are assigned to
complete certain tasks for a group of patients
rather than care for specific patients. For
example, the RN performs all assessments and
administers all intravenous medications; the
LVN/LPN gives all oral medications; and the
assistant performs hygiene tasks and takes
vital signs. A charge nurse makes the
assignments and coordinates the care.

Functional Nursing

Nurse Manager

LVN/LPN
RN
Nurse aide
PO Meds Assessments Vital signs
Treatments Care plans
Hygiene

Nurse aide
Hygiene
Stocking

Assignet Patient Group

The functional nursing care delivery model

Team Nursing
In team nursing the RN functions as a
team leader and coordinates a small
group (no more than four or five) of
ancillary personnel to provide care to a
small group of patients. "As coordinator of
the team, the registered nurse is responsible
for knowing the condition and needs of all
the patients assigned to the team, and for
planning the care of each patient" (Marquis
and Huston, 2000).

Team Nursing
The team leader is responsible for
encouraging a cooperative environment
and maintaining clear communication
between all team members.
The team leader's duties include planning
care, assigning duties, directing and
assisting team members, giving direct
patient care, teaching, and coordinating
patient activities.

Team Nursing
Nurse Manage
RN Team Leader

RN
LVNs/LPNs
Nursing assistants
Assigned patient

group

RN Team Leader
RN
LVNs/LPNs
Nursing assistants
Assigned patient
group

Team nursing model

Advantages of the Team Nursing

Model

1. High-quality, comprehensive care can be

provided with a relatively high proportion of
ancillary staff.
2. Each member of the team is able to
participate in decision making and problem
solving.
3. Each team member is able to contribute
his or her own special expertise or skills in
caring for the patient. (Marquis and Huston, 2000).

Disadvantages of the Team Nursing

Model
1. Continuity of care may suffer if the daily team

assignments vary and the patient is confronted

with many different caregivers.
2. The team leader may not have the leadership
skills required to effectively direct the team and
create a "team spirit."
3. Insufficient time for care planning and
communication leads to unclear goals.
Therefore responsibilities and care may become
fragmented.

TEAM NURSING
Team nursing is an effective, efficient
method of patient care delivery and has
been used in most inpatient and outpatient
health care settings.
The team leader must have strong clinical
skills, good communication skills,
delegation ability, decision-making ability,
and the ability to create a cooperative
working environment.

Modular Nursing
Modular nursing is a modification of team
nursing and focuses on the patient's geographic
location for staff assignments.
The patient unit is divided into modules or
districts, and the same team of caregivers is
assigned consistently to the same geographic
location.
Each location, or module, has an RN assigned
as the team leader, and the other team members
may include LVNs/LPNs and UAP (Yoder Wise, 1999).

Modular Nursing
The concept of modular nursing calls for a smaller
group of staff providing care for a smaller group of
patients.
The goal is to increase the involvement of the RN
in planning and coordinating care.
Communication is more efficient among a smaller
group of team members (Marquis and Huston, 2000).
To maximize efficiency, each designated module
should contain all the supplies needed by the staff
to perform patient care.

Partnership Model
The partnership model, sometimes
referred to as co-primary nursing, is a
modification of primary nursing and was
designed to make more efficient use of
the RN.
In the partnership model the RN is
partnered with an LVN/LPN or UAP,
and the pair work together consistently to
care for an assigned group of patients.

CASE MANAGEMENT
Evolution of Case Management
Case management is a model of care delivery in
which an RN case manager coordinates the
patient's care throughout the course of an
illness.
The concept of case management was first
introduced in the 1970s by insurance
companies as a method to monitor and control
expensive health insurance claims, usually
created by a catastrophic accident or illness (More
and Mandell, 1997).

CASE MANAGEMENT
Today, virtually every major health
insurance company has a case
management program to direct and
manage the use of health care services for
their clients.
Case management by payer organizations
(e.g., health insurance companies, health
maintenance organizations [HMOs]) is
known as external case management.

CASE MANAGEMENT
The ANA has defined nursing case management as
"a dynamic and systematic collaborative approach
to providing and coordinating health care services to
a defined population. It is a participative process to
identify and facilitate options and services for
meeting individuals' health needs, while decreasing
fragmentation and duplication of care and enhancing
quality, cost-effective clinical outcomes. The
framework for nursing care management includes
five components: assessment, planning,
implementation, evaluation, and interaction" (ANCC,

Components of Case Management

Assessment.
Review

the client's history and current status

Perform comprehensive health assessment
Identify available resources and support
system (e.g., individual, family, financial, health
insurance, community)
Identify barriers to accessing necessary
treatment (e.g., lack of health insurance
coverage; no family support)

Components of Case Management

Assessment.
Identify health promotion and disease prevention
opportunities
Identify adherence patterns, educational needs,
and ability to learn
Determine potential for overuse or under use of
resources
Find, appraise, and use research findings as the
basis for treatment decisions (evidence-based
practice)

Components of Case Management

Planning.
Prioritize needs and set realistic, measurable goals
and outcomes
Identify realistic treatment options
Coordinate various providers involved in the plan of
care (e.g., physician, physical therapist, dietitian)
Determine appropriate levels of care and realistic
treatment settings (e.g., home, long-term care,
rehabilitation facility)
Identify and address gaps in care
Ensure continuity of care
Negotiate and manage financial aspects of care

Components of Case Management

Implementation

Ensure implementation of the care plan in a safe,

timely and cost-effective manner
Coordinate services and referrals to providers or
agencies
Ensure compliance with federal, state, and local
regulations and standards
Use appropriate community resources
Document progress toward achieving goals and
outcomes
Accept accountability for implementation of the care
plan

Components of Case Management

Evaluation
Measure clinical goals, functional improvement,
satisfaction with services and cost-benefit of
treatment plan
Is/was the plan of care realistic, collaborative,
and mutually beneficial to all involved?
Are/were the established time frames realistic?
Are/were the best possible and most costeffective treatments used?
Are/were individual educational opportunities
maximized?

Components of Case Management

Interaction
Interact on a daily basis with diverse groups of
people: client, family members, and significant
others; health care team members; payer
representatives; representatives from other health
care agencies and community organizations
Motivate diverse groups to cooperate, collaborate,
and work in the best interest of the client
Use good communication, negotiation,
facilitation, and documentation skills.

CASE MANAGEMENT
Nursing case management in a health care
facility is a supplemental form of nursing
care delivery and does not take the place of
the nursing care delivery model in place to
provide direct patient care.
Case management is not needed for every
patient in a health care facility and generally
is reserved for the chronically ill, seriously ill
or injured, and long-term, high-cost cases.