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
 Variations have been adopted to improve
care
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
Registered Registered Registered
Nurse Nurse Nurse
8-hour shift 8-hour shift 8-hour shift

Patient Care
The registered nurse plans,
organizes, and performs all care

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
 Nurse Manager

LPN/LVN RN Nurse Aide Nurse Aide

PO Meds Assessments Vital signs Hygiene
Treatments Care Plans 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
 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
 Nurse Manager

RN Team Leader RN Team Leader

RN RN
LPNs/LVNs LPNs/LVNs
Nursing Assistants Nursing Assistants

Assigned Patient Group 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
 Nurse Manager

Geographic Geographic Geographic

Patient Unit Patient Unit Patient Unit
Patient Care Patient Care Patient Care
Team: Team: Team:
RNs RNs RNs
LPNs/LVNs LPNs/LVNs LPNs/LVNs
Nurse Aides Nurse Aides Nurse Aides
Meds Meds Meds
Supplies Supplies Supplies
Linens Linens Linens

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 Nurse
24-hour responsibility for
planning, directing & Associate Nurses
Physician and
other members evaluating patient care Provide care
of the health care when primary
team nurse is off duty

Patient

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
 Nurse Manager
Patient Care Respiratory Services Patient Transportation
Housekeeping ECG Admission/Discharge Phlebotomy
Physical/Occupational/Speech Therapy Dietary Services
Financial Counseling Supply Management

Patient

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)
 Collaborates With
Patient and Family

NURSE CASE MANAGER

Onset of Resolution of
Assesses, plans, implements, coordinates,
Illness Illness
monitors, and evaluates patient care
options and services to meet health needs

Collaborates with Nursing, Coordinates Services:

Physicians, Physical/Speech/ Home Care, Hospice,
Occupational Therapists, Dietary, Extended /Long-term Care
and Ancillary Services 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
 Consults  Self-care activities
 Laboratory and  Nutrition
diagnostic tests  Patient and family
 Treatments education
 Medications  Discharge planning
 Safety  Triggers
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?