Rajeshwari S

Lecturer
Community Health Nursing
SEMINAR ON

Rajeshwari, Msc Nursing (CHN)

 Acute care hospital
 Government hospital
 Voluntary hospital.
 For-profit hospital.

Rajeshwari, Msc Nursing (CHN)

Admission
 Direct Emergency

Scheduled

Rajeshwari, Msc Nursing (CHN)

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

Rajeshwari, Msc Nursing (CHN)

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

Rajeshwari, Msc Nursing (CHN)

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

Rajeshwari, Msc Nursing (CHN)

Meeting Organizational Needs

 Budget and financial management

 Number of staff
 Staff mix
 Licensing and accreditation
 Customer satisfaction
 Quality care

Rajeshwari, Msc Nursing (CHN)

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

Rajeshwari, Msc Nursing (CHN)

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

Rajeshwari, Msc Nursing (CHN)

Classic Nursing Care Models

 Total patient care

 Functional nursing
 Team nursing
 Primary nursing
 Variations have been adopted to
improve care

Rajeshwari, Msc Nursing (CHN)

Total patient care

Rajeshwari, Msc Nursing (CHN)

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)

Rajeshwari, Msc Nursing (CHN)

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

Rajeshwari, Msc Nursing (CHN)

Rajeshwari, Msc Nursing (CHN)
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
Rajeshwari, Msc Nursing (CHN)
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

Rajeshwari, Msc Nursing (CHN)

Rajeshwari, Msc Nursing (CHN)
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
Rajeshwari, Msc Nursing (CHN)
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

Rajeshwari, Msc Nursing (CHN)

Rajeshwari, Msc Nursing (CHN)
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

Rajeshwari, Msc Nursing (CHN)

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

Rajeshwari, Msc Nursing (CHN)

Rajeshwari, Msc Nursing (CHN)
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

Rajeshwari, Msc Nursing (CHN)

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

Rajeshwari, Msc Nursing (CHN)

Rajeshwari, Msc Nursing (CHN)
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

Rajeshwari, Msc Nursing (CHN)

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

Rajeshwari, Msc Nursing (CHN)

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
Rajeshwari, Msc Nursing (CHN)
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

Rajeshwari, Msc Nursing (CHN)

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

Rajeshwari, Msc Nursing (CHN)

Rajeshwari, Msc Nursing (CHN)
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

Rajeshwari, Msc Nursing (CHN)

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

Rajeshwari, Msc Nursing (CHN)

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)

Rajeshwari, Msc Nursing (CHN)

Patient centered care

Rajeshwari, Msc Nursing (CHN)

Managed care

Rajeshwari, Msc Nursing (CHN)

Differentiated practice nursing

Rajeshwari, Msc Nursing (CHN)

Shared goverance

Rajeshwari, Msc Nursing (CHN)

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
Rajeshwari, Msc Nursing (CHN)
Clinical Pathways
Terminology

 Patient outcomes
 Transdisciplinary intervention
 Variance
 Trigger

Rajeshwari, Msc Nursing (CHN)

Clinical Pathways
Essential Components
 Consults
 Laboratory and diagnostic tests
 Treatments
 Medications
 Safety
 Self-care activities
 Nutrition
 Patient and family education
 Discharge planning
 Triggers

Rajeshwari, Msc Nursing (CHN)

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?

Rajeshwari, Msc Nursing (CHN)

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

Rajeshwari, Msc Nursing (CHN)

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?
Rajeshwari, Msc Nursing (CHN)