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20 Notes

Activities required to ensure an adequate number and mix of health
care team members to meet patient needs and provide safe, quality
Considerations are patient needs, staff satisfaction, and organizational
Staffing and Patient Needs

Research validates contribution of RNs to improved patient outcomes
and prevention of premature mortality
Primary considerations for staffing a nursing unit
o Number of patients
o Intensity of care required
o Staff experience and preparation
o Geography of the environment
o Available technology
Patient classification systems
o Categorize patients according to care needs (acuity level)
o Higher acuity levels mean that nursing care needs are more
ANA recommends that classification systems should consider patients:
o Age and functional ability
o Communication skills
o Cultural and linguistic diversities
o Severity and urgency of the admitting condition
o Scheduled procedures
o Ability to meet health care requisites
o Availability of social supports
o Other specific needs identified by patient and RN
Staff members must have the educational preparation, skill, and
experience necessary to meet patient care needs
Concerns about inadequate numbers of appropriately skilled and
experienced staff should be addressed with executive level managers

Staffing and Staff Satisfaction
 Satisfied nurses generally provide higher quality, more cost-effective
 24 hours/day, 365 days/year staffing needs make meeting the nurse’s
personal needs difficult

high-quality care Nursing Care Delivery Models  Detail how task assignments. responsibility. competent. and authority are structured to accomplish patient care  Describe which health care worker is going to perform what tasks. professional staff members who are committed to providing safe. 20 Notes  Creative staffing options are available to meet varied needs of staff members  Methods to gain staff input about staffing and to enhance autonomy are the key to staff satisfaction Staffing and Organizational Needs      Organizational needs affected by staffing include: o Financial resources o Licensing regulations and accreditation standards o Customer satisfaction Efficient staff management ensures the organization’s financial solvency Nurse manager accountable for budgetary guidelines for: o Numbers of staff working at any given time o Staff mix RNs the most expensive staff. thus ratios for RNs to other types of care providers may be established o Licensing and accreditation agencies do not impose mandatory staffing ratio but do look for evidence that patients are adequately cared for o Customer satisfaction is critical to an organization’s success o A customer’s personal interaction with employees is key to satisfaction Nurse manager’s number one challenge: o Appropriate staffing within budget constraints with well-trained. and who has the authority to make decisions  Basic premise is that the number and type of caregivers are closely matched to patient care needs in a cost-effective manner Classic Nursing Care Delivery Models     Total patient care Functional nursing Team nursing Primary nursing 2 . who is responsible.Ch.

organizing. and performing all patient care during the assigned shift Background o Oldest method of organizing patient care. possibility of overlooking priority patient needs o Patient may feel confused because of many different care providers o Caregivers may feel unchallenged when performing repetitive functions Common use areas: operating room 3 . sometimes referred to as case nursing o Nursing student typically performs total patient care for assigned patients o Advantages  RN maintains a high degree of practice autonomy  Lines of responsibility and accountability are clear  Patient receives holistic.Ch. unfragmented care  Communication at shift change is simple and direct o Disadvantage  Number of RNs required is very costly  Some tasks could be accomplished by a caregiver with less training and at a lower cost o Common use areas: intensive care units. postanesthesia care units Functional Nursing      Staff members are assigned to complete certain tasks for a group of patients rather than care for specific patients Lines of responsibility and accountability o RN nurse manager assigns responsibility for completion of tasks to a group of health care workers o RN is responsible for planning care and supervising workers o RN retains accountability for the patient care provided Advantages of patient care o Provided economically and efficiently o Minimum number of RNs required for patient care o Tasks completed quickly. 20 Notes  Variations of these classics have been adopted to improve quality and cost-effectiveness of patient care Total Patient Care   Nurse is responsible for planning. little confusion about responsibilities Disadvantages of patient care o May be fragmented.

problem solving o Each member contributes his/her own special expertise or skills  Disadvantages o Continuity of care may suffer with daily team assignments o Team leader may not have the leadership skills required to effectively direct the team o Insufficient time for care planning and communication leads to unclear goals and fragmented care  Common use areas: effective. supervising. and assisting team members  Giving direct care o RN retains accountability for all patient care o RN team leader is responsible for encouraging a cooperative environment and maintaining clear communication  Advantages o High-quality.Ch. same team of caregivers assigned consistently to same geographic location o Each location or module has RN as team leader o Goal is to increase the involvement of the RN in planning and coordinating care o Designated modules should contain all the supplies needed by the staff to maximize efficiency Primary Nursing  RN “primary” nurse assumes 24-hour responsibility for planning. 20 Notes Team Nursing  RN functions as a team leader and coordinates care for a small group of patients  Lines of responsibility and accountability o RN team leader is responsible for the following:  Planning care  Assigning duties  Directing. efficient method of patient care delivery that has been used in most inpatient and outpatient health care settings Modular Nursing  Modification of team nursing o Patient unit divided into modules. and evaluating the patient’s care from admission through discharge o Provides total patient care while on duty 4 . directing. comprehensive care can be provided with a relatively high proportion of ancillary staff o Each member participates in decision making.

20 Notes o While off duty. holistic patient care o Patient able to establish a rapport with the primary nurse. hospice. assigning duties. care is provided by an associate nurse. coordinating care. and supervising the partner o RN is accountable for patient care for all assigned patients  Advantages o More cost-effective than the primary care system o RN can encourage training and growth of partner  Disadvantages o RN may have difficulty delegating to the partner o Consistent partnerships are difficult to maintain on the basis of varied staff schedules 5 . and patient satisfaction is enhanced o Job satisfaction high because nurses are able to practice with a high degree of autonomy and feel challenged and rewarded  Disadvantages o Implementing may be difficult because primary nurse is required to practice with a high degree of responsibility and autonomy o Inadequately prepared primary nurse may not be able to make the necessary clinical decisions or to communicate effectively with the health care team o RN may not be willing to accept 24-hour responsibility as required o Number of RNs required for this method of care may not be costeffective and may be difficult to recruit and train  Common use areas: home health. pair work together consistently  Modification of primary nursing designed to ensure more efficient use of RN  Lines of responsibility and accountability o RN responsible for planning care. who follows the care plan established by the primary nurse  Lines of responsibility and accountability o RN primary nurse has 24-hour responsibility and accountability for patient care o Associate nurses are responsible for following the plan care o RN primary nurse is responsible for maintaining clear communication among all members of the health care team  Advantages o Direct patient care provided by a small number of nurses allows for high-quality.Ch. long-term care Partnership Model (or Co-primary Nursing)  RN is partnered with an LPN/LVN or a nursing assistant.

and preferences  Philosophy of care o Not a typical nursing care delivery model but more a philosophy of care o Should be incorporated as an essential component of any nursing care delivery model  Methods to engage patients’ families. and telephone Nurses’ Roles in Telehealth Nursing  Triage  Interventions  Consultation  Surveillance and follow-up Practice Standards (Published by the American Academy of Ambulatory Care Nursing) 6 .e-mail. internet. and values and ensuring that patient values guide all clinical decisions” o Nurses.Ch. needs. fax. telephone nursing. beginning in the early 1970s  Also called telephone triage. or telehealth  Encompasses all telecommunication methods. and significant others as partners in care o Include them in developing care plans and discharge plans o Include them in change-of-shift or hands-off reports o Provide them with the information and education needed to make informed decisions o Establish “family advisory councils” to engage patients and families in decision making Telehealth Nursing Characteristics  Important method of providing nursing care to clients in ambulatory settings  Formally used to interact with patients. physicians. and other health professionals partner with patients and families to ensure that health care decisions respect patients’ wants. 20 Notes Patient-centered Care  Definition by IOM (2001) o “Providing care that is respectful of and responsive to individual patient preferences. needs.

and to assist the patient to move through the continuum of care  Studies have demonstrated the value of case management in improving patient outcomes and reducing costs  Collaborative approach to providing and coordinating health care services. decreasing fragmentation and duplication of care. as an employee of the payer or as an employee of the health care facility  Goal of case management is to focus attention on quality. most notably social work. have been involved in developing case management programs 7 . or guidelines to assess and address patient needs  Prioritizing the urgency of patient needs  Developing a collaborative plan of care  Evaluating outcomes of practice and care Structure  Integral part of an outpatient clinic practice  Function of a centralized call center Future of Telehealth Nursing  Ever-increasing opportunities for nurses in telehealth to influence the quality of care Case Management Evolution  Introduced in 1970s by insurance companies as a method to monitor and control expensive health insurance claims  Today. outcomes.Ch. and enhancing quality. identifying and facilitating options and services for meeting health needs. cost-effective clinical outcomes  Nurse case manager “manages” a “case load” of patients from preadmission (onset of illness) to discharge (resolution of illness) Case Management in Health Care  Other disciplines. 20 Notes  Using protocols. most health insurance companies have a case management program  By mid-1980s. algorithms. and cost of care. hospitals recognized need for case management to manage patients’ treatment plan and length of stay because of the diagnosis-related group (DRG) payment method  The RN case manager coordinates the patient’s care throughout the course of an illness.

and medical complications such as weaning from mechanical ventilation  Differ from clinical practice guidelines o Clinical pathways define key processes and patient goals in the day-to-day management of care o Clinical practice guidelines guide broader decision making and focus on decisions made in performing a procedure or service Background  Developed to identify quality. common nursing care needs such as immobility. Practice Protocols. 20 Notes  When clinical knowledge is required. high-cost cases Clinical Pathways (Critical Paths.Ch. cost-effective care plans to reduce the patient’s length of stay in the hospital  Dictate the type and amount of care given and thus have financial implications for the health care facility Terminology  Patient outcomes: result of intervention by the health care team 8 . Care Maps) Defining Features  Delineates a predetermined written plan of care for a particular health problem  Specifies desired outcomes and the interdisciplinary intervention required within a specified period for a particular diagnosis or health problem  Written to address common medical diagnoses such as heart failure and pneumonia. the seriously ill or injured. the RN is most effective in the case management role  Variations in case management are found in almost all health care organizations Case Management and Other Nursing Care Delivery Models  Supplemental form of nursing care that does not replace the nursing care delivery model already in place to provide direct patient care  RN case manager assumes a planning and evaluative role and usually is not responsible for direct care duties  Case management is generally reserved for the chronically ill. and long-term.

20 Notes  Interdisciplinary intervention: collaborative effort by all disciplines. along with the patient and family. medicine. pharmacy. and other health care organizations. with representatives from various disciplines such as nursing.Ch. has developed a series of clinical practice guidelines  Developed for the health care organization’s most common or costly diagnoses  A team supported by management. in conjunction with medical specialty associations. and dietary. therapy. develops clinical pathways Choosing a Nursing Care Delivery Model Examples of Different Health Care Settings Requiring Different Models  Emergency departments use financial nursing because emphasis is on efficient assessment and immediate treatment 9 . to reach desired health outcomes  Variance: any event that may alter the patient’s progress through the clinical pathway  Trigger: alerts caregiver that an unexpected event has occurred and identifies potential and actual variations in patient’s response to a planned intervention Essential Components of Clinical Pathways  Consults  Laboratory and diagnostic tests  Treatments and medications  Safety and self-care activities  Nutrition  Patient and family education needs  Discharge planning  May address triggers Development of Clinical Pathways  Based on accepted standards of practice  Medical specialty boards developed clinical practice guidelines  The Agency for Healthcare Research and Quality (AHRQ). professional societies.

Ch. and competencies Evaluation of Nursing Care Delivery Models  Are patient outcomes achieved in a timely. sometimes over the course of a single shift Influences on the Type of Nursing Care Delivery Model Used  Health care Setting o Acute care o Long-term care o Ambulatory care o Home care and hospice  Organizational structure and resources o Management structure o Staffing resources o Supply resources o Physical layout of the facility  Patient needs o Acute o Long-term/chronic  Staff availability. cost-effective manner?  Are patients and families happy with care?  Are physicians and other health team members satisfied with care?  Does the system allow for implementation of the nursing process?  Does the system facilitate communication among all of members of the health care team? Future Nursing Care Delivery Models Factors Influencing Changes in Nursing Care Delivery  Rapid technological advances  Fast-paced patient turnover in acute care settings  RN’s value in patient safety and quality care  Ongoing shortages of nurses and other health professionals  Strong focus on outcomes of care  Consumer demand for instant access to care and information 10 . 20 Notes  Team nursing frequently used in medical-surgical units  Total patient care is common in critical care units  Home health agencies may use primary nursing  A study found that more than 50% of staff from 26 hospitals reported using two or three nursing care delivery models. skills.

Ch. 20 Notes  Need to focus on the underlying determinants of health that are affected by lifestyle and personal choice Nursing Now and in the Future  Traditional models of nursing care focused on comprehensive knowledge of patient needs and care provided over an extended period  Now. and healing  Nurse leaders will be challenged to identify new models that are costeffective. will improve quality and safety of care. nurses may be assigned an entirely new group of patients to care for every shift. caring. or even more than once during a shift  Nurses of the future must conduct focused assessments and set priorities to resolve before the patient is quickly transitioned to another level of care  Nurses in outpatient and community-based settings are challenged to address the following: o Patients’ demands for instant access to care and information o Patients’ need for support and education to address lifestyle and personal choices that may affect their health  Relationship-based care must be considered in high-tech fast-paced environments where care must be consistent with nursing values of compassion. and facilitate relationship-based nursing 11 .