Nursing Care

Delivery Systems
Issues and Trends
Module 6
Five Major Types of Nursing
Care Delivery Systems

• Total Patient Care

• Functional Nursing
• Team or Modular Nursing
• Primary Nursing
• Case Management

Marquis and Huston 2012

 Total Patient Care
• Registered Nurse assumes responsibility for a
group of patients for a shift – provides all care to
the patient.
• Advantages – continuity for the shift,
responsibility is clear, generally satisfying for
nurses.
• Disadvantages – can be very expensive, may not
utilize RN time wisely and may not be possible
with staffing shortages.
 Functional Nursing
• Staff Members are assigned to a specific task or
group of tasks for patients – example Medication
Nurse, IV Nurse, Vital Signs --- RN assumes
overall direction of care.
• Advantages – incorporates the use of LPNs and
UAPs and maximizes their skills, can be cost
effective.
• Disadvantages – Can lead to fragmentation and
gaps in patient care – not holistic.
Team Nursing/Modular Nursing
• RN Team Leader coordinates care for a group of
patients working with other team members
(RNs, LPNs and UAPs) utilizing their skills.
• Advantages – if done well can be very satisfying
to staff and patients as well as cost effective.
• Disadvantages – requires high level leadership
skills from RN – harder to do with high patient
acuity and inconsistent team members.
 Primary Nursing
• Registered Nurses assume 24/7 accountability
for their Primary Patients – establish plan of care
and coordinate care even in their absence.
• Advantages – can result in high job satisfaction
and excellent holistic care for patients.
• Disadvantages – requires high RN mix, difficult to
do with today’s flexible scheduling, some staff
don’t want the accountability and responsibility.
 Case Management
• RN Case Manager supervises the care of the
patient and use of resources across the
continuum – focus is on individual patients.
• Advantages – can be very cost effective and
satisfying for patients who are high risk/problem
prone.
• Disadvantages – Case Management is not a true
inpatient delivery system but rather the
management of patient care.
Leadership Responsibilities in Selecting a
Model
• Determine whether the • Ensure that the model
patient acuity and will allow your nursing
patient needs in the staff to do their best
setting fits the model work.
being recommended.
• Assess whether your • Determine the economic
staff is ready and trained feasibility.
to utilize a new model. • Assess the adequacy of
• Ensure that your staff your nursing resources
understand scope of to support the model.
practice issues.
 Hot Issues with Nursing Care
Delivery Systems
• Movement of Nursing back to a
Team or Modular Approach
• Increasing Numbers of Associate
Degree Nurses with no Leadership
Training who are assigned as Team
Leaders.
• Confusion about Scope of Practice
particularly with LPNs in Acute
Care has led to reduction of LPN
use but an increase in PCA or PCT
Use.
What Every Nursing Leader needs
to know about the Florida Nurse
Practice Act before introducing a
New Nursing Care Delivery System
Supervision - Definition
“Supervision is the provision of guidance by a qualified nurse and
periodic inspection by the nurse for the accomplishment of a
nursing task or activity”
Florida Nurse Practice Act
 Delegation - Definition

“Transferring to a competent individual the authority to perform a

selected nursing task in a selected situation.”

National Council of State Boards of Nursing

Practice of Professional Nursing
• Observation, Assessment, Nursing Diagnosis, Planning,
Intervention, Evaluation of Care and Health Teaching.

• Administration of Medications and Treatments as

prescribed by a duly authorized licensed practitioner in
the state.

• Supervision and Teaching of other personnel in the

performance of the above acts.

Florida Nurse Practice Statute 464

Practice of Practical Nursing
• Performance of selected acts including administration
of treatments and medications in the care of the ill,
injured, or infirm and the promotion of wellness,
maintenance of health and prevention of illness of
others.

• Works under the direction of a Registered Nurse, a

Licensed Physician, a Licensed Osteopath, a Licensed
Podiatric Physician or a Dentist.

Florida Nurse Practice Statute 464

Unlicensed Assistive Personnel -
UAPs
• Certified Nursing Assistants
• Personnel Care Assistants
• Student Nurses
• Patient Care Technicians

• None of the above are licensed

Registered Nurses Cannot Delegate the
Following
• Assessment or
Reassessment of Patients
• Planning of Care
• Evaluation of Care
• Decisions about whether
to contact a Physician
about Changes in a
Patient’s Condition
Registered Nurses can Delegate
• Tasks involving Activities
of Daily Living

• Data Collection such as

Intake/Output, Weights,
Vital Signs, Glucose Finger
Sticks

• Administration of
Medications or
Performance of
Treatments
 Supervision of Care
• Supervision of Care in an Acute Care Setting is
ALWAYS the responsibility of a Registered Nurse.

• Licensed Practical Nurses in Nursing Home

Setting can supervise care given by other LPNs or
UAPs providing that have 6 months experience
and a 30 hour supervisory course.

Florida Nurse Practice Statute 464

Questions to ask before you change
your skill mix?
• What is the acuity mix of your patients and will
RNs be able to safely assign patients to other
levels of staff and provide the level of follow-up
needed?
• Do your RNs clearly understand that LPNs can
never assume full responsibility for acute care
patients?
• Do your RNs and LPNs understand that patient
assessments and reassessments must be done by
Registered Nurses?
More Questions to ask before you change
your skill mix?

• Do your LPNs who have worked in Nursing Homes understand

that their scope of practice is different in acute care settings.
• Do your Registered Nurses have the leadership capabilities to
delegate and provide the level of supervisory follow-up that
acute care patients require?
 Key Information Sites
For Nurse Practice Guidance
• https://www.ncsbn.org/index.htm The National Council of
State Boards of Nursing

• http://www.doh.state.fl.us/mqa/nursing/index.html The
Florida Board of Nursing